2022 Book DepressionBurnoutAndSuicideInP

Depression, Burnout
and Suicide in
Physicians
Insights from Oncology and

Other Medical Professions
Luigi Grassi
Daniel McFarland
Michelle B. Riba
Editors
123
Depression, Burnout and Suicide
in Physicians
Luigi Grassi • Daniel McFarland
Michelle B. Riba
Editors
Depression, Burnout
and Suicide in Physicians
Insights from Oncology and Other
Medical Professions
Editors
Luigi Grassi Daniel McFarland
Department of Neuroscience Department of Medicine
and Rehabilitation Northwell Health Cancer Institute
University of Ferrara Lenox Hill Hospital
Ferrara New York, NY
Italy USA
Michelle B. Riba
Department of Psychiatry
University of Michigan
Rogel Cancer Center
Ann Arbor, MI
USA
ISBN 978-3-030-84784-5 ISBN 978-3-030-84785-2 (eBook)

https://doi.org/10.1007/978-3-030-84785-2
© Springer Nature Switzerland AG 2022

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Foreword
This important volume edited by Michelle Riba, Luigi Grassi, and Daniel McFarland
focuses on burnout, depression, and suicide among medical and oncology profes-
sionals. By addressing a gap in identifying mental health problems among physi-
cians, this book also sheds a light on suicide in the medical profession. Importantly,
this book is a call to action of the professional and administrative organizations to
work on improving mental health of physicians. Anxiety and depression affect not
only the individual doctor but also patient care.
Suicide, with approximately 800,000 deaths per year in the world, constitutes a
great public health problem. Suicide rates among physicians are higher than suicide
rates in the general population. Surprisingly, physicians do not receive adequate
treatment, care, and support from the workplace despite the presence of the compe-
tence and proximity to colleagues specialized in early recognition and treatment of
mental health problems and mental disorders.
One of the first articles that reported higher mortality, for all causes of deaths,
among doctors was published in the 1880s in England and Wales. Much has changed
since then. Doctors today have lower mortality for somatic diseases in comparison
with the general population. But not for suicide. Since the 1960s, many studies have
shown the high suicide frequency among doctors in comparison with the general
population, and highest for female doctors. Female doctors generally experience
more challenges with balance between work and family life than their male col-
leagues, despite growing numbers of males who are nowadays more involved in
family responsibilities in comparison with previous generations.
Doctors have suicidal thoughts; they attempt suicide and commit suicide at least
twice that of the general population. Depressive symptoms are a risk factor for sui-
cidality, also in the cases when clinical criteria for depression are not present. For
physicians who have chosen the profession to contribute to health and to save lives,
the confrontation with oncological patients, who despite a great progress in diag-
nostics and treatment still have low survival chances, can be emotionally burden-
some. Responsibility for care of terminally ill patients often lead to compassion
fatigue and moral distress. Lack of communication skills about difficult diagnosis
and prognosis are burdensome for doctors.
Many factors in the workplace can cause burnout due to increasing burden of
clinical workload and occupational demands contra limited decision making, too
many bureaucratic tasks, and computerization. A feeling of being an unimportant
v
vi Foreword
and maybe not enough appreciated part in the chain of health producing system cor-
relates with burnout. Among different psychosocial risk factors, problems in the
workplace significantly contribute to suicide among doctors.
Families of doctors are frustrated, as well as social life can be truncated. Poor
healthy lifestyle choices like lack of daily exercise, insufficient sleep, too few cul-
tural and social activities on top of the frustrated family life can easily be replaced
with binge eating, smoking, use of prescription drugs to calm down, drinking alco-
hol, or smoking marijuana.
Most physicians, especially males, do not seek help. There are several reasons
for that. The fear of losing the medical license and psychologically to be ashamed
about not being able to take care of oneself are prominent. Female doctors are more
prone than male doctors to admit to psychological problems and seek help. If they
seek help, they do not dare to seek public help services. In many countries, mental
disease is an obstacle to work as physician, like it is for one with alcohol or drug
dependency. A doctor doesn’t want to challenge serious repercussions on
one’s career.
It is still uncustomary to speak about mental health problems among physicians
at the workplace and within professional organizations. Employers should develop
attractive prevention programs which are adjusted to the needs of the doctors to
meet the worries about disclosure, lack of anonymity, and improving work condi-
tions. Having a natural meeting place for colleagues to speak about not only difficult
cases but also about emotional and practical difficulties when coping with everyday
life of being a doctor is important.
Awareness and appropriate mental health promoting and suicide preventive pro-
grams decrease the stress and increase positive coping strategies. Education about
these problems should be given at all medical faculties, to educate future physicians
how to preserve and improve their own mental health. A similar education is neces-
sary for administrators and people responsible for healthcare and public mental
healthcare systems for a future of better public mental health among professionals
and better care for patients.
Burnout, depression, and suicide are major health issues among physicians
around the world. This book, through an international perspective from renowned
psychiatrists and medical oncologists, will significantly increase the awareness and
contribute to understanding of the necessity of preventive measures on individual,
family, and care givers levels. I highly recommend this excellent book to all physi-
cians and as a training literature in medical schools and schools for healthcare orga-
nization and administration.
Danuta Wasserman
M.D., Ph.D., Professor of Psychiatry and Suicidology Head and Founder of
National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP),
Karolinska Institutet, Stockholm, Sweden Director for WHO Collaborating Centre
for Research, Methods Development and Training in Suicide PreventionPresident-
Elect for the World Psychiatric Association (WPA)
Preface
It is a privilege in medicine that we enter the private space where patients are at their
most vulnerable and personal. In only recent history have social concerns and mores
evolved to such an extent that we can now ask the right questions about how physi-
cians experience work stresses and how these situations not only effect our work but
may be improved. Despite our passion for healing and understanding the human
condition, hardly a year goes by without news of yet another self-inflicted, physi-
cian tragedy. Many of us know and have known suffering at various times during
our careers. For many, it strikes during training or as an early career physician,
which may be particularly heartbreaking.
Thankfully, attention to this topic is increasing. Our hope is that sustainable sys-
temic solutions are on the horizon. Inspiration for this book emerged alongside a
symposium we were honored to deliver at the 2019 Annual Meeting for the American
Society of Clinical Oncology, entitled “The Elephant in the Room: Addressing
Depression and Suicide Among Oncology Providers.” Our thoughts on the topic
solidified into the chapters of this book, which were meant to provide a reference
and contextual basis for each one of these interrelated topics. We believe that there
is something invaluable to be gained for all physicians, in all areas of medicine, by
taking a hard look inward and asking the difficult questions about how we do what
we do and if we are honoring ourselves, our families, and our patients in the process.
At this point, too much is known to disavowal the inner life of the clinician from
the practice of medicine. A modern-day Francis Peabody may have been tempted to
proclaim an additional important truth, “for the secret of the care of the patient is in
caring for the patient,” and also “the secret is in caring for the clinician.” This book
is dedicated to those whose lives are touched by clinicians and physicians we hold
dear. We are indebted to our chapter authors and all physicians who accompany us
on this journey.
New York, NY, USA Daniel McFarland

Ferrara, Italy Luigi Grassi
Ann Arbor, MI, USA Michelle B. Riba
vii
Acknowledgments
We are deeply grateful to all the colleagues and friends that, as authors of the chap-
ters, accepted to be part of this project and to share their clinical experience as
protagonists of their specific area of expertise. We owe a debt of gratitude to the
board of the World Psychiatric Association (WPA), particularly the WPA Section on
Psycho-Oncology and Palliative Care and the WPA Section on Psychiatry, Medicine
& Primary Care. We thank our colleagues and staff at the Institute of Psychiatry,
Department of Neurosciences and Rehabilitation, University of Ferrara, Italy; the
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering
Cancer Center, New York, USA; and the Department of Psychiatry and University
of Michigan Rogel Cancer Center, University of Michigan, USA. We also extend
our acknowledgments to the staff of Springer, for their help and guidance. We are
deeply indebted to our teachers and mentors, our loved ones who constantly encour-
aged us over the years, and all the “persons” (patients and their families, colleagues)
who, directly or indirectly, have been and are constantly part of the exercise of the
art and the science of medicine.
ix
Contents
1 The Problem of Burnout, Depression, and Suicide in

Physicians: A General Overview�� 1
Luigi Grassi, Daniel McFarland, and Michelle B. Riba
2 Medical Professionalism and Physician Dignity: Are We at
Risk of Losing It? �� 11
3 Burnout in Medicine�� 27
Jamie Riches, Maria Giulia Nanni, Federica Folesani, and
Rebecca Guest
4 Depression and Substance Use Disorders in Physicians�� 37
Martino Belvederi Murri, Marta Gancitano, Fabio Antenora,
Mona Mojtahedzadeh, and Jaroslava Salman
5 Suicide and Suicide Risk in Physicians�� 55
Isabella Berardelli, Sally Spencer-Thomas, Luca Germano,
Andrea Barbetti, and Maurizio Pompili
6 Screening and Assessment of Burnout with a Focus on Oncology
Healthcare Providers �� 69
Emily Kantoff, Konstantina Matsoukas, and Andrew Roth
7 The Ethical Implications of Burnout: A Moral Imperative
to Prioritize Physician Well-Being, Resilience, and
Professional Fulfillment�� 87
Fay J. Hlubocky, Mehmet E. Dokucu, and Anthony L. Back
8 Euthanasia and Medical Assistance in Dying as
Challenges for Physicians’ Well-Being�� 113
Luigi Grassi, Karandeep Sonu Gaind, Tristan Nash, and
Rosangela Caruso
9 Moral Distress in Physicians �� 127
Diya Banerjee and Yesne Alici
xi
xii Contents
10 Embitterment in the Workplace �� 137

Michael Linden and Christopher P. Arnold
11 Prevention of Burnout Through Resilience, Wellness
Programs, and Civility in the Work Environment�� 147
Caroline M. Kissane and David W. Kissane
12 Cultivating Resilience and Preventing Burnout: A Mindful
Multipronged Intervention Approach�� 157
Fernando Kawai and Daniel McFarland
Index�� 177
Contributors
Yesne Alici Weill Cornell Medical College, New York, NY, USA
Fabio Antenora Institute of Psychiatry, Department of Neuroscience and
Rehabilitation, University of Ferrara, Ferrara, Italy
Christopher P. Arnold Charité University Medicine Berlin, Department of
Psychosomatic Medicine, Research Group Psychosomatic Rehabilitation,
Berlin, Germany
Anthony L. Back Division of Oncology, University of Washington, Fred
Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
Diya Banerjee Department of Psychiatry and Behavioral Sciences, Memorial
Sloan Kettering Cancer Center, New York, NY, USA
Andrea Barbetti Psychiatry Residency Training Program, Faculty of Medicine
and Psychology, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
Isabella Berardelli Department of Neurosciences, Mental Health and Sensory
Organs, Faculty of Medicine and Psychology, Suicide Prevention Centre,
Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
Rosangela Caruso Department of Neuroscience and Rehabilitation, University of
Ferrara, Ferrara, Italy
Mehmet E. Dokucu Northwestern University Feinberg School of Medicine,
Department of Psychiatry and Behavioral Sciences, Chicago, IL, USA
Federica Folesani Institute of Psychiatry, Department of Neuroscience and
Karandeep Sonu Gaind Governing Council and Division of Adult Psychiatry and
Health Systems, University of Toronto, Toronto, ON, Canada
Department of Psychiatry, Humber River Hospital, Toronto, ON, Canada
World Psychiatric Association, Geneva, Switzerland
Marta Gancitano Institute of Psychiatry, Department of Neuroscience and
xiii
xiv Contributors
Luca Germano Psychiatry Residency Training Program, Faculty of Medicine and

Psychology, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
Luigi Grassi Department of Neuroscience and Rehabilitation, University of
Ferrara, Ferrara, Italy
Rebecca Guest Department of Employee Health and Wellness, Memorial Sloan
Kettering Cancer Center, New York, NY, USA
Fay J. Hlubocky The University of Chicago Medicine, Department of Medicine,
Section of Hematology/Oncology, Maclean Center for Clinical Medical Ethics,
Program for Supportive Oncology, Chicago, IL, USA
Emily Kantoff Department of Psychiatry and Behavioral Sciences, Memorial
Fernando Kawai Department of Medicine, New York Presbyterian Queens/Weill
Cornell Medical College, Flushing, NY, USA
Caroline M. Kissane Department of Paediatrics, Royal Children’s Hospital,
Parkville, VIC, Australia
David W. Kissane University of Notre Dame Australia and Cunningham Centre
for Palliative Care Research, St Vincent’s Hospital, Sydney, NSW, Australia
Cabrini Health Psycho-oncology Unit, Monash University, Malvern, VIC, Australia
Michael Linden Berlin, Deutschland
Charité University Medicine Berlin, Department of Psychosomatic Medicine,
Research Group Psychosomatic Rehabilitation, Berlin, Germany
Konstantina Matsoukas Medical Library, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
Daniel McFarland Department of Medicine, Northwell Health Cancer Institute,
Lenox Hill Hospital, New York, NY, USA
Mona Mojtahedzadeh Department of Supportive Care Medicine, City of Hope,
Los Angeles, CA, USA
Martino Belvederi Murri Institute of Psychiatry, Department of Neuroscience
and Rehabilitation, University of Ferrara, Ferrara, Italy
Maria Giulia Nanni Institute of Psychiatry, Department of Neuroscience and
Tristan Nash University of Wales Trinity Saint David, London, UK
Maurizio Pompili Department of Neurosciences, Mental Health and Sensory
Organs, Faculty of Medicine and Psychology, Suicide Prevention Centre,
Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
Contributors xv
Michelle B. Riba Department of Psychiatry, University of Michigan, Rogel Cancer

Center, Ann Arbor, MI, USA
Jamie Riches Department of Medicine, Memorial Sloan Kettering Cancer Center,
New York, NY, USA
Andrew Roth Department of Psychiatry and Behavioral Sciences, Memorial
Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
Jaroslava Salman Department of Supportive Care Medicine, City of Hope, Los
Angeles, CA, USA
Sally Spencer-Thomas United Suicide Survivors International, Denver, CO, USA
The Problem of Burnout, Depression,
and Suicide in Physicians: A General 1
Overview
Introduction
The need to understand the psychological burden to be a physician is extremely

important despite the fact that daily interactions with practice administrators,
patients, and even physicians themselves may not consider the psychological bur-
den of being a physician to be a problem. The general preconception that Physicians
should be at lesser risk for suffering or can “heal themselves” is antiquated and
harmful. They are not invincible and, as all human beings, have limits that should be
always properly addressed [1].
It is unfortunate that the medical profession is considered cold, “clinical,” and
impersonal by many in society. An overreliance on technology regardless of its ben-
efits may be at fault to a large extent. The good news is that it is not the whole story.
The “Promethean Gap,” which was first espoused by Gunther Anders as a theory to
understand the innate fear of technology, explains the easily construed fallacy to
overly value the “created,” that is, medical technology, over the “creator,” the
humanity for which the technology is used to assist in providing medical care [2].
Medicine is not alone in the feeling that technology has created a more impersonal
world. At its core, however, it is exactly the opposite. Essentially, medicine is based
on relationships with patients in which Physicians, as human beings, unavoidably
L. Grassi
Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
e-mail: [email protected]
D. McFarland (*)
Department of Medicine, Northwell Health Cancer Institute, Lenox Hill Hospital,
New York, NY, USA
M. B. Riba
Department of Psychiatry, University of Michigan, Rogel Cancer Center,
Ann Arbor, MI, USA
© Springer Nature Switzerland AG 2022 1

L. Grassi et al. (eds.), Depression, Burnout and Suicide in Physicians,
https://doi.org/10.1007/978-3-030-84785-2_1
2 L. Grassi et al.
bring their personal history, their life events, and their inner emotional world. And,
as Zinn underscores [3], it is impossible that the medical encounter, like all human
interactions, cannot be emotion laden. When dealing with the problematic life situ-
ations of their patients, especially, but not only, serious illness, a number of affective
responses emerge. Part of them are related to the role strain or the sense of failure
and frustration, part to the not infrequent feelings of powerlessness against the clini-
cal situation of their patients and its associated losses, the grief, part to the fear of
becoming ill oneself or a desire to separate from and avoid patients to escape these
feelings [4]. If these emotional responses are accompanied by an exaggerated sense
of duty and obligation in attending to the demands of the patients and their families,
the denial of one’s own dependency needs and gratification, or the attempt to
increase work efficiency within a magical thinking of one’s own immunity to one’s
own suffering, the situation can be only complicated. Also, the significant change in
the organization of the healthcare systems, mainly the corporation and bureaucrati-
zation of the medical profession, associated with administrative burden, inefficient
workflow patterns, and increasing patient load expectation has only increased the
risk for physicians to develop emotional disorders.
eneral Issues About Burnout, Depression, and Suicide

G
Among Physicians
Attention to this area has increased over the last 40 years with a series of data accu-
mulating on the problems of emotional exhaustion and use of detaching defensive
mechanisms leading to poor and cold interaction with the patients, personal sense of
failure, and demoralization. These dimensions, conceptualized as burnout, have
become popular since the first studies carried out in the 1970s and the increasing use
of one of the first specific scales, the Maslach Burnout Inventory, that was devel-
oped in those years. Burnout was in fact described as a “psychosomatic” clinical
condition typical of healthcare professionals in which they lose their state of well-
being. It is a syndrome characterized, as abovementioned, by emotional exhaustion,
tendency to be detached toward their patients, and poorly perceiving a sense of self-
fulfillment and meaning in their own profession which can lead to specific psycho-
logical disorders, including depression and substance abuse, and the risk for
suicide [5, 6].
The literature regarding burnout among physicians is nowadays somewhat cum-
bersome, with data showing that at least one-third or more of physicians have devel-
oped the core symptoms of this work-related condition. Burnout as work-workplace
mismatch has highlighted many of the issues working in modern healthcare arena
that can rob the clinician of the meaningful and purposefulness with which they had
originally set out in their medical career trajectory. All specialties are affected by
this negative emotional and behavioral state, with a very high number of studies
available especially, but not exclusively, in oncology, palliative care, emergency
medicine, psychiatry, and anesthesiology [7].
1 The Problem of Burnout, Depression, and Suicide in Physicians: A General Overview 3
The risk factors for burnout, the consequences of burnout on the patients as well
as on physicians, the preventive measures of this condition, and the possible main
intervention have been described in detail by hundreds of studies. Most authors
underline the fact that burnout is the unintended net result of multiple, highly dis-
ruptive changes in society at large, the medical profession, and the healthcare sys-
tem. Both individual and organizational strategies have been only partially successful
in mitigating burnout and in developing resiliency and well-being among physi-
cians [8].
A travesty in its own right, common mental health issues have also garnered
increased attention alongside the increasingly evident problem of burnout. As said
above, full-blown psychiatric conditions including depression and substance abuse
and the risk for suicide in the medical profession have been known since the times
of Hippocrates and are more recently investigated with some rigor. Today we know
that the consequences of depression and untreated depression among physicians are
extremely negative. General physical health of physicians is put at risk by both
burnout and depression [9]; physicians not only showing burnout symptoms but
resulting positive to screening for depressive symptoms are at higher risk for medi-
cal errors, with obvious negative consequences on patient satisfaction and care [10,
11]; and physicians’ depression is related to the problems at work and risk of patient
complaints and dissatisfaction [12]. Depression, but other psychiatric disorders as
well, is notoriously related to suicide ideation and suicide. Data have also accumu-
lated regarding physician depression and suicide. The latest investigations confirm
the following: (1) suicide is higher among physicians than the general population;
(2) in contrast with general epidemiological data indicating that males are at higher
risk for suicide, among physicians it is the opposite, with more females than males
committing suicide; and (3) some specialties, such as psychiatry, anesthesiology,
and surgery, are at highest risk. This has been confirmed by reviews and meta-
analysis that indicate that females, in terms of gender, and anesthesiologists, psy-
chiatrists, general practitioners, and general surgeons, in terms of specialty, are at
higher risk [13, 14] (Table 1.1).
The rate of suicide in physicians seem to be a little different between the USA
and Europe. Studies carried out in the USA report 1.4–2.3 times the rate achieved in
the general population (28–40 per 100,000 vs 12.3 per 100,000 in general popula-
tion), with higher rate among female physicians (2.5–4 times) [13, 16]. For that
reason, suicide of physicians has been underlined by media as a silent epidemics to
which attention should be paid urgently. In Europe there are contrasting data, some
showing that suicide among physicians has decreased over the last 20 years (with
rate similar to the general population) [12], while in other countries, including the
UK, Norway, Denmark, and others, the suicide rate is higher among physicians,
with rates of about two times that of the general population [17–20]. Similar pat-
terns were found among Australian physicians [21, 22].
Although untreated (or under-treated) depression, bipolar disorder, or substance
misuse is, as said, considered the most important factor for suicide in physicians, as
it is for the general population [23], the suicide risk factors for doctors, as Gerada
4 L. Grassi et al.
Table 1.1 Ten facts about physicians’ suicide and mental health (from the American Foundation
for Suicide prevention – mod) [15]
1. Suicide generally is caused by the convergence of multiple risk factors — the most
common being untreated or inadequately managed mental health conditions
2. An estimated 3–400 physicians die by suicide in the USA per year (comparable data in
European countries are less available)
3. Physicians who took their lives were less likely to be receiving mental health treatment
compared with nonphysicians who took their lives even though depression was found to
be a significant risk factor at approximately the same rate in both groups
4. The suicide rate among male physicians is 1.41 times higher than the general male
population. And among female physicians, the relative risk is even more pronounced –
2.27 times greater than the general female population
5. Suicide is the second-leading cause of death in the 24–34 age range (accidents are the
first)
6. Twenty-eight percent of residents experience a major depressive episode during training
versus 7–8% of similarly aged individuals in the US general population
7. Among physicians, risk for suicide increases when mental health conditions go
unaddressed, and self-medication occurs as a way to address anxiety, insomnia, or other
distressing symptoms. Although self-medicating, mainly with prescription medications,
may reduce some symptoms, the underlying health problem is not effectively treated. This
can lead to a tragic outcome
8. In one study, 23% of interns had suicidal thoughts. However, among those interns who
completed four sessions of web-based cognitive behavior therapy, suicidal ideation
decreased by nearly 50%
9. Drivers of burnout include workload, work inefficiency, lack of autonomy and meaning in
work, and work-home conflict
10. Unaddressed mental health conditions, in the long run, are more likely to have a negative
impact on a physician’s professional reputation and practice than reaching out for help
early
correctly underlines [24], go beyond mental illness. These factors should be exam-
ined with careful attention since they regard not only the physician as an individual
but the context in which physicians work including the constant contact with the
suffering and death of other human beings, as well as the series of organizational
work-related stressors [25].
Oncology as a medical subspecialty is at a unique apex of this crisis. While the
same pressures in medicine certainly apply to oncologists, such as increasing
administrative burden, oncology is a changing field with diverse patient and societal
expectations for outcomes. That is, oncologists still treat many patients who will
ultimately succumb to their cancer diagnoses and experience the inherent stress
repeatedly from those encounters, but they are also confronted with an onslaught of
new medical information and a landscape that is changing at a breakneck pace.
These two factors, (1) managing terminally ill patients and (2) becoming outstripped
of imperative medical knowledge, provide unprecedented demands for this field.
Rates of burnout among oncologists are essentially in the middle of medical subspe-
cialties, with studies suggesting a prevalence of 35% among medical oncologists,
38% among radiation oncologists, and 28–36% among surgical oncologists [26].
However their rates of depression are higher among oncologists than other internist,
and this is coupled with higher risk for suicidal ideation and suicide [27]. Therefore,
understanding the interplay of common mental health workplace issues (depression,
burnout) and the workplace demands as related to suicide should be specifically
addressed not only among oncologist [28, 29] but in the medical field in general [30].
The worldwide emergency of SARS CoV2 pandemic and the role of physicians
in the front line dealing with the devastating complication of COVID-19 are very
recent examples of how all physicians in all specialties are involved in the risk of
emotional suffering and should be protected in all the possible ways to warrant good
clinical care for their patients [31–33].
A serious problem brought to the attention of psychiatry is that burnout, depres-
sion, and the risk for suicide not only affect senior physicians but younger doctors
as well as residents and students entering the field and the profession of medicine.
Their risk for psychological disorders and suicide in medical students and trainees
has not examined deeply, although new data are accumulating [34–36]. Many
authors underline the fact that this problem is not recognized enough or not reported
because of lack of transparency, by the academic or related institutions [37, 38]. In
effect, about 10% of medical students report suicidal ideation, and suicide is the
second leading cause of death among resident trainees in the USA (4.1 per 100,000).
Recently Blacker et al. [39] called on the national organizing bodies of medical
education to mandate reporting of deaths by suicide and to create and maintain a
database for tracking and studying these events, given the fact that the phenomenon
is under-reported and under-examined.
All these issues indicate the urgent need to sensitize the political and administra-
tive system of hospital and community services to address this problem and to put
it among priorities in their agenda. In the USA, the American Medical Association
(AMA) has long advocated for improving our knowledge about better caring for
physician populations [40–42]. Hospital organizations should increasingly recog-
nize physician wellness as a key factor for success in this competitive healthcare
market in the USA and across the world [43]. Limited resources means optimizing
the invaluable resources (physicians and other clinicians) that are available.
The literature is rife with calls for increasing awareness, understanding, and
interventions, although the science behind addressing this complicated psychoso-
cial issue is not straightforward [44]. Empiric science can only tell us so much about
what should be done because types of intervention vary widely as do specific prac-
tice settings. There are however many good examples of a priori-derived interven-
tions that provide proof of concept and beyond. Recent review and meta-analyses
show that various types of interventions (alone or in group, online or face to face,
using cognitive behavioral therapies (CBT) or mindfulness and other kinds of inter-
vention) have been shown to be beneficial, reducing rates of burnout, depression,
and suicide [45, 46]. Physicians who present with symptoms of burnout or depres-
sion should be part of special programs both in terms of prevention and treatment at
6 L. Grassi et al.
the workplace, in order to reduce the risk of suicidal ideation and suicide [47].
Psychiatry has a prominent role in this and should demonstrate strong and effective
alliances with other healthcare system specialties. In addition, psychiatry can be
invaluable for physicians needing help since other physicians are needed to demon-
strate an understanding of their medicalized worlds and its effect on wellness and
happiness [48, 49]. It has to be emphasized, however, that structural or organiza-
tional intervention (e.g., workload or schedule rotation, stress management training
program, teamwork/transitions) is imperative [50, 51]. Physician mental health
problems are often the result of organizational dysfunction and stressors and affect
the entire healthcare organization rather than single physician individuals and their
families [52]. Incorporating interventions into real life with the help of health policy
makers, administrators, healthcare organizations, and clinical managers to design
simple and feasible strategies may be complicated but is certainly mandatory in
order to improve physicians’ well-being via modification of the work environment.
Mental Healthcare of Physicians as an Ethical Duty
With this background in mind, we have considered that time has come to summarize
the story of mental health issues among medical clinicians, the unique issues of
some specialties in this respect, particularly but not only oncology, and a greater
understanding of how burnout and other emotional problems work, highlighting
available data-driven knowledge with expert opinion about best practices for physi-
cians and organizations alike moving forward.
This book coalesces several important physician mental health issues (i.e.,
depression, burnout, and suicide) and discusses each separately but often refers to
them collectively throughout the book. Our aim is to present these interrelated
issues as their implications (i.e., for patients, physicians, and society) are similar
and their treatments also overlap. We are fully convinced that the paradigm of dig-
nity should be applied to physicians and that dignity-in-care, in its wider sense,
within the dyadic doctor-patient relationship, means to recuperate the personhood
of the physician as a human being (Chap. 2). In addition to thoughtful introductions
and discussions of physician burnout (Chap. 3), depression (Chap. 4), suicide
(Chap. 5), and embitterment (as a dysfunctional, behavioral, and emotional response
to health work-related burdens and interactional stressors) (Chap. 10), we also intro-
duce practical topics on screening and assessing these dimensions and clinical con-
ditions in physicians (Chap. 6), its prevention in institution/work environments
(Chap. 11), and interventions (Chap. 12). This book also explores the psychological
impact of euthanasia and medical assisting in dying on physicians (Chap. 8) and
moral distress (Chap. 9) as challenges that physicians face. The ethical implications
(Chap. 7) of these issues are relevant for all physicians and for society. Attention to
this area has created an opportunity for reflection and improvement so that the prac-
tice of medicine is sustainable for all physicians who experience adversity or feel
misplaced in their work environment.
Conclusions
On these bases, our hope is to stimulate awareness and advocate for physician men-
tal health to collectively enhance physician and patient well-being along with
improved healthcare quality through medical disciplines. In many ways, this is a
nascent field with very old roots that is beginning to see a time of renewed interest
and hope for a mentally healthier healthcare workforce. Some of the problems are
new while many are quite perennial. Exploration of the topic is far from over, how-
ever, and much improvement remains to be seen. Our hope is to bring together the
interrelationship of these topics and the need for information from a more human-
ized and person-centered approach [53] that we consider the essence of medicine,
not only for the patients but also for the healthcare professionals as part of the sys-
tem of care.
Acknowledgments
We are deeply grateful to all the colleagues and friends that, as authors of the chap-
ters, accepted to be part of this project and to share their clinical experience as
protagonists of their specific area of expertise. We owe a debt of gratitude to the
board of the World Psychiatric Association (WPA), particularly the WPA Section on
Psycho-Oncology and Palliative Care and the WPA Section on Psychiatry, Medicine
& Primary Care. We thank our colleagues and staff at the Institute of Psychiatry,
Department of Neuroscience and Rehabilitation, University of Ferrara, Italy; the
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering
Cancer Center, New York, USA; and the Department of Psychiatry and University
of Michigan Rogel Cancer Center, University of Michigan, USA. We also extend
our acknowledgments to the staff of Springer, for their help and guidance. We are
deeply indebted to our teachers and mentors, our loved ones who constantly encour-
aged us over the years, and all the “persons” (patients and their families, colleagues)
who, directly or indirectly, have been and are constantly part of the exercise of the
art and the science of medicine.
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Medical Professionalism and Physician
Dignity: Are We at Risk of Losing It? 2
Introduction
To be a physician means to be a professional who practices the “art and science” of

medicine, which means promoting, maintaining, or restoring health through the
study, diagnosis, prognosis, and treatment of disease, injury, and other physical and
mental impairments. For centuries, the Hippocratic Oath has been used by physi-
cians to express these meanings where the dedication of oneself to a sustained sense
of humanity expressed through the spirit of medicine is part of the person (the doc-
tor) who has decided to cure and take care of another person who is sick (the
patient) [1].
As a modern successor to the Hippocratic Oath for physicians, the Declaration of
Geneva, adopted by the second General Assembly of the World Medical Association
(WMA) (Geneva, Switzerland, September 1948) and more recently amended at the
68th WMA General Assembly (Chicago, USA, October 2017) [2], has been made
more modern according to the new characteristics medicine has developed, espe-
cially in the last 100 years (Table 2.1). Some of these changes from the Hippocratic
L. Grassi (*)
D. McFarland
New York, NY, USA
M. B. Riba
Department of Psychiatry, University of Michigan, Rogel Cancer Center,
Ann Arbor, MI, USA

12 L. Grassi et al.
Table 2.1 The Hippocratic Oath [3] and 68th WMA General Assembly Declaration of Geneva
Hippocratic Oath WMA General Assembly Declaration of Geneva
I swear by Apollo Physician and Asclepius As a member of the medical profession:
and Hygieia and Panaceia and all the gods I solemnly pledge to dedicate my life to the
and goddesses, making them my witnesses, service of humanity
that I will fulfill according to my ability and The health and well-being of my patient will be
judgment this oath and this covenant: my first consideration
To hold him who has taught me this art as I will respect the autonomy and dignity of my
equal to my parents and to live my life in patient
partnership with him, and if he is in need of I will maintain the utmost respect for human life
money to give him a share of mine, and to I will not permit considerations of age, disease
regard his offspring as equal to my brothers or disability, creed, ethnic origin, gender,
in male lineage and to teach them this nationality, political affiliation, race, sexual
art—if they desire to learn it—without fee orientation, social standing or any other factor to
and covenant; to give a share of precepts intervene between my duty and my patient
and oral instruction and all the other I will respect the secrets that are confided in me,
learning to my sons and to the sons of him even after the patient has died
who has instructed me and to pupils who I will practice my profession with conscience
have signed the covenant and have taken an and dignity and in accordance with good medical
oath according to the medical law, but no practice
one else I will foster the honour and noble traditions of
I will apply dietetic measures for the benefit the medical profession
of the sick according to my ability and I will give to my teachers, colleagues, and
judgment; I will keep them from harm and students the respect and gratitude that is their
injustice due
I will neither give a deadly drug to anybody I will share my medical knowledge for the
who asked for it, nor will I make a benefit of the patient and the advancement of
suggestion to this effect. Similarly, I will healthcare
not give to a woman an abortive remedy. In I will attend to my own health, well-being, and
purity and holiness, I will guard my life and abilities in order to provide care of the highest
my art standard
I will not use the knife, not even on I will not use my medical knowledge to violate
sufferers from stone, but will withdraw in human rights and civil liberties, even under
favor of such men as are engaged in this threat
work I make these promises solemnly, freely and upon
Whatever houses I may visit, I will come my honour
for the benefit of the sick, remaining free of
all intentional injustice, of all mischief and
in particular of sexual relations with both
female and male persons, be they free or
slaves
What I may see or hear in the course of the
treatment or even outside of the treatment
in regard to the life of men, which on no
account one must spread abroad, I will keep
to myself, holding such things shameful to
be spoken about
If I fulfill this oath and do not violate it,
may it be granted to me to enjoy life and
art, being honored with fame among all
men for all time to come; if I transgress it
and swear falsely, may the opposite of all
this be my lot
2 Medical Professionalism and Physician Dignity: Are We at Risk of Losing It? 13
Oath to this Declaration are related to the art of medicine becoming less predomi-
nant, while the science has increased its influence in the new global worldview
(Weltanschauung). As a point, although it is possibly true that the duality, art and
science in medicine, may be an artifact [4], there is the risk, as Van Der Weyden
notes [5], that the art of medicine (as the capacity to listen to patients, to see them
in all the dimensions, as persons first, then as a disease) can lose its relevance in the
new millennium, due to both the increased level of technology and “cold” science
in medicine and the bureaucratic modifications of the healthcare system. Certainly,
there are many other reasons regarding these changes, including the requests to the
health system based on the WHO “right to health” which contrasts with the costs of
it in a constantly fluctuating economy and the inequalities between countries; the
need for medicine and doctors to care more about the person and not only the dis-
ease; the predominance of the evidence-based paradigms (e.g., rigid clinical meth-
ods with only objective perspectives and quantitative measurement searching for
one absolute quantifiable objective “truth”) in opposition to a rising person-oriented
value-based medicine (including narrative-based medicine) (e.g., with flexible
methods and subjective perspectives gained through qualitative approaches and
awareness of the relativity of “truths”) [6–10].
Many scholars of the medicine of the last century, such as Francis Peabody [11]
or Paul Tournier [12], and of the psychosomatic, consultation-liaison psychiatry and
psychological medicine areas, such as Franz Alexander [13], Michael Balint [14],
Zbigniew J. Lipowski [15], or George L. Engel [16], supported the view of medi-
cine’s integrity as a humanistic, altruistic, and compassionate discipline. Following
their legacy, we firmly consider that, more now than ever, it is important to recog-
nize the science of medicine as a territory of the encounter between human beings
and the need to “re-humanize” medicine, underscoring the centrality of humans and
the human experience in health and illness [17, 18].
Therefore, it is necessary to restate the value of the physician as a human being,
before being a professional (in its several meanings, such as a scientist, a “techni-
cian,” a healer, a miracle-maker, and so on, determined by different cultures) [19–
21]. It is a fact that, as indicated in the WMA documents, the revised Declaration
mentioned above refocuses the text to reflect the changes in medicine over the
decades, including the transformation of the relationship between physicians and
their patients and between physicians themselves. Also, among the several new
obligations on physicians, a requirement for physicians has been added, that is, to
attend to their own health, well-being, and abilities in order to provide care of the
highest standard.
If it is true that the individual who develops a disease is a person (patient), the
individual who acts by applying medical “techniques” (physician) is a person, too.
In this chapter we will discuss the sense of being a physician and the sense of dig-
nity that according to a person-centered approach in medicine should, by definition,
regard the interaction between human beings, as persons [22, 23].
14 L. Grassi et al.
Doctor-Patient Dyad and Physician’s Personal Dignity
Dignity is a concept that permeates medicine and that has become part of the vast
literature that underscores the extremely important need to relate to patients as per-
sons, by showing empathy, respect, and compassion, as indicated in the Hippocratic
Oath and in its new modern version [24–26].
Dignity derives from the Latin nouns decus (ornament, distinction, honor, glory,
but also worthiness of honor and esteem) and dignitas, which is “an individual or
group’s sense of self-respect and self-worth, physical and psychological integrity
and empowerment” [27, 28]. In this sense, dignity relates to both the individual and
the interpersonal dimensions of the human being: individual, as the inherent and
inalienable value that belongs to every human being simply by virtue of being
human (dignity-of-self, the dignity we attach to ourselves as integrated and autono-
mous persons), and interpersonal, as the worthiness of respect that demands affir-
mation and calls for action, approval, and support (dignity-in-relation, the dignity
that the individual perceives or does not perceive in the eyes of others within inter-
personal relationships) [29, 30]. According to Sulmasy [31] these concepts can be
expressed in terms of intrinsic dignity, which refers to worth, stature, or value that
human beings have simply because they are human, and attributed dignity, which
refers to worth, stature, or value that human beings confer upon others by acts of
affirmation.
We refer the reader elsewhere for the vast literature relative to the paradigm of
dignity in medicine and the movement of dignity-in-care, as the mandatory obliga-
tion of patients to be respected as persons and the medical system to relate with
patients in a holistic way, meaning in all the dimensions (biological, psychological,
social, and spiritual) characterizing the human being [32–34]. It is a fact that, in line
with person-centered medicine, the promotion of a medicine of the person (of the
totality of the person’s health, including its ill and positive aspects), for the person
(promoting the fulfillment of the person’s life project), by the person (with clini-
cians extending themselves as full human beings with high ethical aspirations), and
with the person (working respectfully, in collaboration and in an empowering man-
ner) is the paradigm of medicine [35].
Here, by understanding the fact that we are speaking of a dyad of human beings
and of an “interpersonal” relationship, we would like to underscore the sense of
dignity regarding the doctor, by considering the emotional implications of being a
physician, as a person first, and the problem of compassion fatigue and burnout, as
significant events related to the medical profession, on which the literature has con-
centrated attention over the last decades.
We summarize herein just a few issues that are in our opinion relevant in modern
medicine and that can be a threat to the dignity of physicians: the commercial inter-
pretation of the healthcare system and its transformation over time, the changes in
the doctor-patient relationship (with the risk of losing the sense of a person-person
relationship), and the problem of not considering the personhood of the physician as
a human being.
The Change in the Healthcare System
The place where doctors and patients meet has profoundly changed over time.
Almost 70 years ago, the psychiatrist and philosopher Karl Jaspers [36] warned
about the problem of an increasingly “technically enhanced” medicine where the
risks for physicians would have been to have their patients reduced to objects with-
out its specific individuality, but also, and at the same time, physicians would be
victims of technological instruments and losing their own identity. The only way for
Jaspers to counteract the regressive aspects of this situation and to avoid the risk that
physicians could be progressively deprived of ethical values and weakened in their
meeting, listening, and cooperating for the good of their patients is to reinstate the
ancient model of the physician-philosopher, according to the Hippocratic medicine.
Of course, Jaspers’ conviction was that the philosophy of medicine (or philosophy
as a guiding framework for a humanized approach to human beings) could help in
giving back the voice to the “art” with respect to the “science.”
Years later, Pellegrino [37] also recommended how to prevent indignity in medi-
cine and in healthcare systems, which, as he stated, has been transformed in “bureau-
cratic, commercialized, and impersonal places that hospitals have, all too often,
become. […].” However, if it is true, as Pellegrino says that “[…] a more collective
sense of shared responsibility for the ‘dehumanization,’ the ‘depersonalization,’ or
the ‘alienation’ that the sick feel in today’s health and medical care institutions […]
in today’s mechanized experience of illness” (page 532), it is also true that the
changes in the healthcare system are not determined by the physicians, who are in
turn victims of the same problem. Today, as some scholars suggest [38] “Hippocratic
medicine” has been replaced by a “Bionic Hippocratism,” where the distinction
between man and machine, natural and artificial, makes the physician become a
Hippocratic technological hybrid. Unwittingly, a paradox emerges. While technol-
ogy is meant to be an auxiliary service to physicians, the physician is more and
more of service to technology and a peripheral foot piece to it. The relationship
between subjects (doctor-patient, as a person to person approach) can be replaced
by a relationship between objects (machine-disease, as a robot-broken apparatus
approach).
Starting in the 1980s, patient safety, cost containment, and quality outcomes for
patients became increasingly recognized as laudable goals for hospitals and admin-
istrative entities to undertake. Many of these outcomes have improved with consis-
tent measurement and attention, but the highly bureaucratic nature of healthcare as
a business subject to an increasing array of metrics and financial bottom line pres-
sures has caused significant damage to the age-old covenant of the doctor-patient
relationship and the health of the physician. In this sense what is defined the “Triple
Aim” (i.e., improving patient experiences, reducing costs, and improving popula-
tion health), as adopted by policy makers, has in fact directly or indirectly trans-
formed and, for some scholars [39], changed for the worse the atmosphere of the
hospital and community health work environments. The high bureaucratization of
contemporary medical practice and health care have clearly created a paradox, since
16 L. Grassi et al.
bureaucracies are inherently impersonal, in contrast with the doctor-patient rela-

tionship (and person-centered care) which is an inherently interpersonal endeavor
[40]. The increase of work load with large patient volumes, insufficient resources,
the pervasive feeling of being poorly staffed and managed by “anonymous” sys-
tems, the lack of control over one’s work environment, and having a lot of time at
work spent on tasks (e.g., administrative and bureaucratic work) are further issues
to be considered [41]. In effect, the more budget issues (including the downsize of
human resource to save money) and high-technological systems take over in a ser-
vice/productive-laden medicine, the more there is the risk of impacting the human-
ity at the basis of medicine, including, as far as physicians are concerned, the onset
of psychological strain and distress, emotional conflicts, and consequences on one’s
own health [42], as we will discuss in the next paragraphs.
In this situation, it is indicated that workplaces can become a possible threat to
healthcare professionals’ dignity, where the lack of respect, as an essential compo-
nent of an organization, undermines the intrinsic characteristics of a healthy envi-
ronment in which patients feel cared for as individuals and members of healthcare
teams are engaged, collaborative, and committed to service, as persons too. In this
view, the need to “re-humanize” or “re-personalize” medicine is based not only on
working on the dyadic (doctor-patient) relationship but on the health system as
well [43].
The Change in Doctor-Patient Relationship
Patient-centered medicine has become a common theme in the literature [44–47],

but this concept seems to forget a significant point, that is, that we are speaking of a
“two-person medicine,” where the doctor is an integral part. For this reason, differ-
ent scholars, including ourselves, use the concept of person-centered medicine [23,
48–50] which recuperates the original work done by Tournier [12] and Balint [14],
in his specific attention to the biunivocal doctor-patient relationship. Later Enid
Eichholz Balint [51] in fact clarifies that the “doctor and patient are influencing each
other all the time and cannot be considered separately” (p. 13) [52]. The doctor’s
subjectivity is therefore regarded inherent in the doctor-patient relationship, with an
influence of the patient toward the physician and vice versa, where sensitivity and
insight into the reactions of both parties can be used for diagnostic (in terms of
knowledge) and therapeutic (in terms of cure and care) purposes. The medical
encounter, like all human interaction, is in fact unavoidably emotion laden, with the
need for emotional responses of the physician to be analyzed for information about
certainly the patient but, as said, also the physician [53].
It is true that in recent years what has been described as possible kinds of doctor-
patient relationships has notably changed. If we refer to what Szazs and Hollender
[54] wrote 50 years ago, the relationship between a doctor and a patient was reflected
along three possible pathways based on an autonomy-dependency axis: (1) an
activity-passivity model (parent-infant model), with an active role of the physician
toward a passive recipient patient that places the physician in absolute control of the
situation, gratifies needs for mastery, and contributes to feelings of superiority for
the physician; (2) a guidance-cooperation model (parent-child/adolescent model)
with a conductive physician toward an obedient patient which provides an opportu-
nity to recreate and to gratify the “Pygmalion Complex” (the physician can mold
others into his own image, as God is said to have created man or he may mold them
into his own image of what they should be like); and (3) a mutual participation
model (adult-adult model) with a helping physician toward a participant patient
highlighting the notion of friendship and partnership and the imparting of expert
advice and in which the physician’s gratification cannot stem from power or from
the control over someone else but derives from more abstract kinds of mastery,
which were at that time as yet poorly understood.
Likewise, Pierre-Bernard Schneider [55] described several kinds of relation-
ships, each with its own peculiarities, based on a subject-object (person-thing) axis.
In the objectifying state, it is possible to consider the “scientific-informative” rela-
tion (based on a scientific objective approach); the “repairing” relation (based on a
mechanical attitude in which the physician is requested by a patient to be fixed); the
“service-maintenance” relation (based on a chronic state of monitoring the persis-
tent problems of the patient, typical of chronic conditions); and the “consultant”
relation (where the doctor is called on the spot for one consultation and then disap-
pears). In the more subjective state, the relation is more interpersonal, such as in the
“interpersonal-subjective” relation (based on a sincere and authentic meeting
between two human beings) or the “supportive” relation where the physician
extends himself/herself to support and help the patient.
Later, Emanuel and Emanuel [56] described four models of the doctor-patient
relationship, namely, a paternalistic (physician as a guardian of the patient), infor-
mative (physician as a competent technical expert), interpretive (physician as coun-
selor or adviser), and deliberative (physician as friend or teacher). The authors
suggested the need for a passage from a paternalistic model, which is justified dur-
ing emergencies when the time taken to obtain informed consent might irreversibly
harm the patient, to an autonomy process. The debate regarding the need to abandon
a paternalistic approach and to have patients completely informed about their clini-
cal situation and to help them decide about what to do, in a shared decision-making
process [57, 58], has enormously increased in the last years, toward a patient-
centered medicine [59, 60].
It is clear that the balance between a technically skillful, rational, and emotion-
ally detached doctor (selling the “product” requested by the system) and a more
emotionally and authentically engaged physician with his/her own feelings (which
is the basis for empathy and compassion) is not easy, with a quite evident prevalence
in modern medicine of the first over the second. However, both intrinsic and attrib-
uted dignity, as defined above, should regard physicians (and healthcare profession-
als in general), too, as persons participating to a human interpersonal relationship,
even if in a professional context, with their patients. In this sense, compassion,
empathy, and sympathy could be considered variables in a transaction optimizing
the care provided to patients while, at the same time, protecting and respecting
healthcare providers in the process [61].
18 L. Grassi et al.
The Personhood Behind the Medical Profession
Professionalism and humanistic health care is contingent on not only respect for
patients (i.e., patient-centered care) but also on systems that allow physicians to
practice with dignity. In all likelihood, this can only be accomplished by under-
standing and respecting the needs of physicians as persons interacting with their
environments and its inherent stressors.
In the last decades, the vulnerability of physicians as persons has in fact become
the focus of attention with studies not only recommending specific training in com-
munication skills and in receiving emotional support [62, 63] but also the urgent
need to improve the working conditions for the healthcare workforce (the so-called
Quadruple Aim instead of the reductivist Triple Aim) [64, 65], where the constant
confrontation with suffering, death and dying, and emergencies in a cold, detached,
mechanical bureaucratic place can be taken into extreme consideration [66].
Data regarding the risk of emotional suffering up to psychological disturbances
in physicians has been pointed out for years. The role strain, leading to excessive
drug use in an attempt to increase work efficiency, the denial of the physician’s own
dependency needs and gratification, and the problems of identity related to the
exaggerated sense of duty and obligation the physician feels in attending to the
demands of the patients and their families have been noted since the 1970s [67–71].
Of course, the causes of emotional problems in physicians are multiple, including,
as for all individuals, childhood problems, life stressful events, or personality char-
acteristics [72]. However, the changes in the health systems and the transformation
of medicine and the technological and market forces, without citing the violent acts
to which physicians and health care professionals are exposed in the workplace
[73], cannot be ignored. Today the concepts of burnout, work stress, and compas-
sion fatigue, as psychological conditions typical of the helping professions, which
can lead to more defined psychological disorders, are important aspects to be care-
fully taken into consideration.
Burnout
Freudenberger [74] and Maslach [75] described burnout as an experience of physi-
cal, emotional, and mental exhaustion in healthcare professionals caused by long-
term involvement in situations that are emotionally demanding (emotional
exhaustion). As reported, when emotional resources are depleted, it is common for
physicians to feel they are no longer able to give of themselves at a psychological
level, with the onset of negative, cynical attitudes and feelings about their patients
(depersonalization). As a further consequence, professionals start to evaluate them-
selves negatively and to feel unhappy and dissatisfied with their accomplishments
on the job (reduced professional and personal accomplishment) with easy deteriora-
tion in the quality of care or service, job turnover, absenteeism, and low morale. The
evaluation of burnout and the dimensions that characterize this condition, as formu-
lated by Maslach and Jackson [76], has become extremely important in the several
medical specialties [77, 78]. In a recent review of 182 studies involving 109,628
physicians in 45 countries, burnout among physicians affected 67.0% of them, with
Table 2.2 Interrelated concepts of burnout, moral distress, compassion fatigue, vicarious
traumatization
Burnout: a syndrome classically characterized by three dimensions: (1) feelings of energy
depletion or exhaustion; (2) increased mental distance from one’s job, or feelings of
negativism or cynicism related to one’s job; (3) reduced professional efficacy and poor
realization of oneself
Moral distress: feeling of personal conflict, dissonance and ethical dilemma, and job
dissatisfaction in healthcare professionals related to institutional constraints, healthcare
systems pressure as regards institutional regulations, budget requirements, and relationship
conflict with patient family members or others
Compassion fatigue: a progressive and cumulative outcome of prolonged, continuous, and
intense contact with patients, self-utilization, and exposure to multidimensional stress leading
to a compassion discomfort exceeding the endurance levels of healthcare professionals
Vicarious traumatization (secondary traumatic stress): negative changes in the clinician’s view
of self, others, and the world resulting in healthcare professionals dealing with patients’
trauma-related thoughts, memories, and emotions, but more generally for the repeated
empathic engagement with ill patients
72.0% reporting emotional exhaustion, 68.1% depersonalization and detachment in

their relationship with their patients, and 63.2% low personal accomplishment and
job satisfaction [79].
Recently burnout has been described not just as a “normal” consequence of
working in the healthcare field. The new 11th edition of the International
Classification of Diseases (ICD) of the World Health Organization (WHO) lists
burnout as an occupational syndrome (with the code QD85) within chapter 24
“Factors influencing health status or contact with health services” [80]. In the
ICD-11, burnout is described as a condition “resulting from chronic workplace
stress that has not been successfully managed […] which refers specifically to phe-
nomena in the occupational context and should not be applied to describe experi-
ences in other areas of life” (Table 2.2).
ompassion Fatigue and Moral Distress

C
Within this framework, compassion fatigue, as a psychological and physical stress
condition determined in physicians and healthcare professionals by a prolonged
contact with patients’ suffering, has also been examined in the medical literature
[81, 82]. It is a concept which is in part related to burnout but also to moral distress
and vicarious traumatization (or secondary traumatic stress) which are also factors
related to work and work stress, as “cost of caring” and possible contributors to the
loss of compassion in healthcare [83] (Table 2.2). Data of studies in several settings
show different prevalence of compassion fatigue (affecting up to 40%) and second-
ary traumatic stress (affecting up to 38%) indicating the need for great attention to
these phenomena [84–87].
Both burnout and its related conditions have significant negative consequences
severely impacting not only the patients’ outcome [88–90] but physicians’ profes-
sion and physicians’ health as well [91], The symptoms are in fact represented by
exhaustion, insomnia, somatization, headaches, stomachaches, sleep disturbance,
20 L. Grassi et al.
fatigue, as well as reduced immunity, risk of cardiovascular and musculoskeletal

disorders [92], diabetes [93], and other physical disorders [94–96], often associated
with depression (as a systemic disease) [97–99].
Therefore, without attention to the emotional life of physicians and their person-
hood, it is hard to imagine that the practice of medicine could implement the dignity-
in-care and compassion models, repeatedly recommended as the essence of medicine
[24, 100]. In effect, recent literature has clearly shown that burnout is a problem of
the whole healthcare organization, rather than individuals, and that intervention pro-
grams specifically devoted to reduce the emotional suffering of physicians should
adopt an organization-directed approach [101]. Burnout symptoms, especially
detachment and depersonalization and poor professional and personal accomplish-
ment, may be better treated if changes and improvement of the “sick” organization
are pursued rather than by acting on the physicians only [102, 103]. A recent model,
for example, indicates that leaders of healthcare systems should address physicians’
basic physical and mental health needs first, then patient and physician physical
safety, and then higher-order needs (e.g., respect from colleagues, patients, pro-
cesses; appreciation and connection) [104]. The WHO itself is developing evidence-
based guidelines on mental well-being in the workplace which take into account the
areas of work life related to burnout (i.e., workload, control, reward, community,
fairness, and values) [105] and act to mold them in a positive way for physicians and
healthcare professionals in general.
Conclusions
In this chapter we have illuminated issues around physician personhood in the mod-
ern healthcare environment in relation to the provision of patient-centered care.
Physician mental health issues are not new but rather being exacerbated by changes
in medicine such as the high tech demands; environmental changes, such as in prac-
tice settings; and corporate culture.
We have considered that the more medicine has become a high-tech area, with a
relationship based on “services to be provided,” the more the human side of medi-
cine has been put at risk in favor of a commercial territory where health can be
bought and high expectations and every request can be met. With respect to this, the
new language spoken into the healthcare system where the despotism of bureau-
cracy, budgeting, and downsizing of resources is by definition far away from the
humanistic approach is based on commerce which is not the expression of true
medical care. Maybe this is in part related to the general crisis of evidence-based
medicine and the sense of a new scientific paradigm which are frequently debated
(e.g., as we have discussed, holistic, humanistic, narrative, and narrative evidence-
based medicine) and synthetized in person-centered medicine.
We are also aware that, speaking in terms of doctor-patient relationships, the old
“paternalistic” practice of a solemn profession, with the relative aura of healing
around it, has also the risk to denigrate the sense of humanity and to consider – as it
was in the past – physicians like gods rather than human beings, with all their limi-
tations. It is understandable that being in a position to ask for the help of someone
who is considered the rescuer and the healer means that the rescuer and healer are
not only invulnerable but able to solve every possible situation. However, the trans-
formation of paternalistic medicine to a joint decision-making relationship has also
risks, and it is perhaps not sufficient to give a sense of parity between the contractors
of a therapeutic covenant. Certainly, the shift from physician paternalism [charac-
terized by professional dominance one up/one down] to patient autonomy [charac-
terized by a client-profession responsibility one up/one up] should take into
consideration the respect for the physician with the human side of him/her. The
ambiguity is in fact that for some aspects it is a bidirectional relationship (e.g., “we
have to make shared decisions as partners”), but not for others (e.g., “you are the
doctor and should perfectly fix my problem, being you and only you responsible for
the outcome”), with inequalities in the humanized relationship between the sick and
the healer. These changes, along with what described in terms of bureaucracy and
corporatization of the healthcare system, typical of modern medicine, expose physi-
cians to risks for their own health, especially mental health which is at higher risk
than in the past.
On these bases, we have discussed the need, within a person-centered approach,
to consider the person of the physician. Literature has repeatedly pointed out in the
last decades the role of burnout and its related dimensions (e.g., compassion fatigue,
moral distress) in reducing the satisfaction of patients and the outcomes in terms of
their health but also in impacting the psychological and physical health of physi-
cians as well. It is therefore extremely important, as Miles indicated [10], that a
modern person-centered medicine really takes full account of all the dimensions,
physical, emotional, spiritual, and social, of the patient, but, we have to add, of the
physician as the member of the system of care as well. Without the attention by the
healthcare system to the human side (with all its strengths and limitations) of the
physician as a person, too, it will be difficult to propose and practice a humanized
medicine.
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Burnout in Medicine
3
Jamie Riches, Maria Giulia Nanni, Federica Folesani,
and Rebecca Guest
Introduction
Burnout is a prevalent and important occupational hazard, experienced by a multi-

tude of physicians across specialties and throughout the career trajectory. The term
burnout is used to characterize a complex syndrome of emotional exhaustion, deper-
sonalization, and self-perceived low personal accomplishment. Burnout results
from prolonged stress in the workplace [1] and is considered specific to occupations
requiring intense interactions with other people [2].
History and Definition of Burnout
The concept of burnout could be found in a vast literature, as the term “to burn out”
appears to have been used also by Shakespeare, among other authors [3]. The first
appearance of the term burnout in the scientific world has been attributed to the
psychoanalyst Herbert Freudenberger [4] who in 1974 described a condition he
observed among volunteers in free clinics for drug abuse. This concept was then
J. Riches
Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
M. G. Nanni · F. Folesani
Institute of Psychiatry, Department of Neuroscience and Rehabilitation,
University of Ferrara, Ferrara, Italy
e-mail: [email protected]; [email protected]
R. Guest (*)
Department of Employee Health and Wellness, Memorial Sloan Kettering Cancer Center,
New York, NY, USA

28 J. Riches et al.
further and independently characterized by Christina Maslach and colleagues,

beginning in the 1970s. Maslach published innovative research, describing the syn-
drome of burnout within human service-oriented professions (e.g., clergy, police,
social workers, teachers, medical) [5], and developed a self-reporting tool to assess
burnout. The complexity and heterogeneity of factors contributing to burnout
result in varying manifestations of symptoms among individuals, though physi-
cians are at higher risk for overall burnout compared to general population con-
trols, with burnout nearly two times as prevalent among physicians versus other
US workers [4]. Though this chapter will focus on the concept of burnout in
terms of its connotations in the medical field, implications and consequences
overlap with other entities, especially compassion fatigue and depression, and
the burnout experience among physicians in various specialties. It is important to
note that burnout impacts clinicians in various roles (e.g., nurses, advanced prac-
tice providers, respiratory therapists) and practice settings. In the 1980s, the ini-
tial primarily qualitative research became more empirical, and the now famous
Maslach Burnout Inventory (MBI) survey was used to quantitatively assess the
syndrome across caregiving professions. In the 1990s and beyond, burnout
research has grown in terms of the number and style of measurement tools as
well as the scope of occupations being evaluated (e.g., education, medicine, law,
law enforcement, ministry).
Burnout is seen as the final step in a progression of unsuccessful attempts to cope
with a variety of negative stress conditions [6]. The WHO does not recognize burn-
out as a medical condition but as an occupational phenomenon.
In fact, ICD-11 [4] states that “burnout is a syndrome conceptualized as resulting
from chronic workplace stress that has not been successfully managed. It’s charac-
terized by 3 dimensions: (1) Feelings of energy depletion or exhaustion; (2)
Increased mental distance from one’s job, or feeling of negativism or cynicism
related to one’s job; (3) Reduced professional efficacy.” The ICD-11 continues:
“Burnout refers specifically to phenomena in the occupational context and should
not be applied to describe experiences in other areas of life.”
Different tests have been developed to assess burnout, among which the
Maslach Burnout Inventory (MBI) is the most widely used. It is a self-report,
comprising 22 items measured on a 7-point Likert scale considering three
domains, according to the burnout model developed by Maslach [7] and parallels
the ICD-11 definition:
1. Emotional exhaustion (EE): the exhaustion domain describes a condition of

fatigue, loss of energy, and debilitation.
2. Depersonalization (DP): also named cynicism, this dimension is characterized
by irritability, withdrawal, and issues in the relationship with the clients.
3. Personal accomplishment (PA): also named inefficacy, this dimension refers to a
diminished productivity, low morale, and inability to cope.
A burnout profile is characterized by high levels of emotional exhaustion and

depersonalization and low levels of personal accomplishment.
3 Burnout in Medicine 29
The Experience of Burnout and Its Tragic Implications
The experience of burnout has a negative impact on a physician’s personal and pro-
fessional health and well-being. Burnout is associated with increased risk for car-
diovascular disease and shorter life expectancy, problematic alcohol use, broken
relationships, depression, and suicide [8]. A number of studies have found that phy-
sician burnout is adversely associated with quality and safety (e.g., medical error),
patients’ satisfaction with their care, professionalism, communication, turnover or
early retirement of impacted clinicians, and healthcare costs. Collective drivers of
physician burnout include loss of autonomy, decreased meaning in work, decreased
control, and inefficient use of time due to increased administrative requirements,
sleep deprivation, isolation, large debt burden (from educational loans), excessive
workloads, and lack of work-life integration [8].
Burnout and Overlap with Depression and Compassion Fatigue
In addition to elevated risk for occupational burnout, the prevalence of depression

or depressive symptoms is alarmingly high in physicians [9]. Despite debate about
overlap, depression and burnout are distinct entities, with discrete measurement
tools. Though burnout should not be overlooked as a modifiable risk and aggravat-
ing factor for depression, conceptualizing burnout as depression risks missing the
opportunity to address its organizational, structural, and societal drivers [10].
Burnout, depression, and work-related stress display some correlations and over-
laps, but they are three different constructs. On the one hand, symptoms of burnout
and aspects of an individual life easily resemble depression, but on the other hand,
burnout is more context-specific: in fact, it arises from distress in the workplace and
exerts effects in the work environment [11]. Furthermore, burnout dimensions as
measured by the MBI do not correspond to depressive symptoms: while correlations
were observed between depression and EE, this was not the case for depression and
PA, and only a minor correlation was observed between depression and DP [12].
However, depression and burnout are indeed two related constructs, as it is possible
that burnout may lead to an increased risk for developing mental disorders: a longi-
tudinal study observed that burnout predicted the risk of taking antidepressants in an
8-year follow-up [13]. Work-related stress when prolonged leads to burnout; how-
ever occupational stress may arise in every kind of profession, while burnout is
considered more specific to jobs where interpersonal relationships, and especially
relationships of care, have a great role.
The Importance of Measuring Burnout
There is considerable variability in how researchers studying physicians, medical

students, and trainees have defined and measured burnout. Variability in measure-
ment tools can have significant implications, including underestimation of the rate
30 J. Riches et al.
of burnout across populations [14]. A meta-analysis on 65 studies from 1991 to

2001 on physician burnout observed that emotional exhaustion appeared to be the
core dimension of burnout [15]; the authors observed both regional differences
between American and European physicians and differences between outpatients
and inpatients specialties in terms of factors contributing to emotional exhaustion.
However, in a systematic review of 182 studies between 1991 and 2018, there was
substantial disagreement in the literature on what constituted burnout, finding at
least 142 unique definitions for meeting overall burnout or burnout subscale criteria
[16]. In a 2015 longitudinal study, Shanafelt and colleagues found the prevalence of
physicians reporting burnout symptoms to be 54.4% [9]. The 2019 Medscape
National Physician Burnout, Depression & Suicide Report found similar rates,
ranging from 32% to 54%, varying by specialty [17]. Most studies of burnout use
surveys in which respondents self-report their feelings, attitudes, beliefs, and behav-
iors relating to their work. The Maslach Burnout Inventory, demonstrated to be
reliable and valid and extensively studied, is the gold standard in burnout assess-
ment for healthcare professionals. Other tools capture distinctive psychosocial,
functional, and occupational measures. Examples of measurement tools specifically
designed for physicians are the Mini-Z, offered by the American Medical
Association, and the Stanford Professional Fulfillment Index, which has questions
on both burnout and well-being.
Differences in prevalence of burnout exist among medical specialties, with
higher prevalence often seen among physicians working on the “front lines” of
patient care [4, 17]. It has been theorized that physicians are especially disposed to
burnout due to traits, such as compulsiveness, precision, high expectations, and
compassion, which facilitate success in medical education, training, and practice
[18]. These traits, in addition to tolerance for a professional environment that stig-
matizes self-care, illness, and perceived weakness and promotes denial of vulnera-
bility, perfectionism, isolation, and delayed gratification, simultaneously create
chronic emotional and interpersonal stressors that contribute to burnout. Theoretical
frameworks now more explicitly integrate both individual and situational factors
[19]. There is a growing appreciation that drivers of physician burnout are not solely
individual but often system-based stressors within the healthcare industry such as
the electronic medical record, payment systems that are burdensome, loss of auton-
omy and control over workplace issues by physicians, and other cultural, economic,
and environmental factors.
Burnout Considerations Among Distinct Specialties
Oncology
The prevalence of burnout among oncologists is similar to that of US physicians

overall, and the satisfaction with career and specialty choice is higher [20]. Long
hours, the administration of often highly toxic therapeutics, and regular exposure to
death and suffering create unique stressors for medical oncologists. There is an
incremental relationship between time devoted to patient care and oncologists’
burnout. Among medical oncologists, many of the risk factors for burnout differ
between practice settings (academic vs. private) [20–22]. Given projected shortages
of medical oncologists in the upcoming decade, studies evaluating interventions
that may sustain career satisfaction and/or reduce burnout are needed in this
population.
Palliative Care
Stressors unique to pain/palliative care physicians include regularly facing difficult

symptoms of terminal and serious progressive illnesses, distressed patients and
families, stigmatization, suffering, and death. Despite these challenges, studies
show that the frequency of emotional exhaustion and depersonalization are lower
among palliative care physicians than in populations interacting with similar
patients, such as oncologists [23–25]. Physicians in palliative care have a high
degree of job satisfaction; they report being less overwhelmed, fewer conflicts,
being less worried about drug toxicity, to have access to better resources, and to
have better communication skills with patients [24].
General Internal Medicine and Hospitalists
General internists suffer higher rates of burnout and lower satisfaction with work-
life balance than most specialties, and overall rates of burnout among hospitalists
and outpatient general internal medicine physicians are reported to be similar [26].
The field of hospital medicine has experienced rapid growth, with an increasing
number of hospitalists in academic medical centers. The rapid evolution of the field
creates potential complications for academic success and career promotion and sus-
tainability of academic hospitalists. In addition to these distinctive complications,
stressors such as amount of control over work schedule (particularly reporting less
protected time for scholarly activity, increased clinical time on nonteaching ser-
vices) and level of support from organizational leaders are predictors of overall low
job satisfaction among hospitalist physicians [27]. Oncology hospitalists provide
acute care for seriously and terminally ill cancer patients in the hospital. Oncology
hospitalists thus face similar emotional stressors as those of oncologist and pallia-
tive care physicians. Importantly, compared to other physician groups, hospitalist
physicians are more likely to agree that their work schedule leaves enough time for
their personal life and family [26], which suggests positive implications for quality
of life in this population.
32 J. Riches et al.
Surgical Specialties
Surgical training and practice present significant challenges that can lead to sub-
stantial personal distress for the individual surgeon and their family. Across multi-
ple subspecialties, surgeons experience a high frequency of burnout and low mental
quality of life (time for personal/family life), though most report being generally
satisfied with their career and specialty choice [28]. Surgical oncologists are not
immune to the previously discussed stressors nor the psychiatric morbidity and
burnout associated with providing care to patients with cancer. Surgical oncology
generates high levels of stress and emotional exhaustion, with the potential for mal-
adaptive coping responses and dependence on a culture of productivity and “bra-
vado” without thoughtful self-care. Compared to general surgical practices,
however, cancer surgeons reportedly achieve more personal fulfillment and less fre-
quently use distancing methods to cope with their patients [29].
Emergency Medicine
A recent Medscape study of burnout across medical specialties showed 43% burn-
out among emergency medicine physicians, a prevalence similar to the average of
all specialties. This marks an improvement over the last few years, but caution
should be taken before concluding that the trend will continue, particularly in light
of the extreme stressors of these frontline clinicians related to the COVID-19 pan-
demic. In addition to the more commonly understood drivers of burnout across spe-
cialties, burnout in emergency medicine is associated with high anxiety caused by
concern for bad outcomes [30]; work overload (e.g., increased number of shifts per
month); chronic fatigue of circadian rhythm disruption; dissatisfaction with institu-
tional support including from specialty services; higher than average risk of medi-
colegal litigation; and the physician’s sense of existential meaning derived from
work [31]. A recent national survey of 1522 US emergency medicine residents
across 247 residencies showed an alarming prevalence of 76% burnout, which is
among the highest rate of resident burnout across specialties. Burnout among these
trainees is due to a higher degree of depersonalization versus attending emergency
medicine physicians and other specialty physicians [32]. Negative and cynical atti-
tudes are a predictable outcome when young physicians are overworked, caring for
high acuity patients in environments that are often under-resourced.
Psychiatry
Risk factors for burnout in psychiatrists may involve patients, physicians, and orga-
nizations. The issue of violence in the workplace is especially important in psychi-
atric setting and perceived as an important source of stress, being associated with
higher levels of emotional exhaustion and depersonalization [33]. Patient suicide
has an important impact on physicians’ personal lives, psychological health, and
management of their job and is subjectively considered as a major stressor in the

psychiatric profession [34]. Engaging with traumatized patients is associated with a
greater stress, leading to the manifestations of burnout [1]. Confronting patients’
families and their high expectations may contribute to the emotional exhaustion of
psychiatrists, especially when facing particularly demanding cases [15]. Other
patient characteristics display an influence on burnout, such as the severity of the
mental disorder and the suspect of malingering.
Psychiatrists tend to display personality traits such as high neuroticism, open-
ness and agreeableness, and low conscientiousness in comparison to other physi-
cians that may predispose them toward stress [14]; also the attachment style [15]
and coping mechanisms [19] were associated with stress in work relationship and
burnout. Psychiatrists may also feel stigmatized in their profession and experience
increased stress [17, 18]. Organizational characteristics also play a role in the devel-
opment or prevention of burnout for psychiatrists and other physicians. Some gen-
eral organizational factors include workload (i.e., the capacity of meeting work
demands), control (i.e., perceived autonomy and ability to influence decisions in the
workplace), reward (i.e., feeling fulfilled by work), institutional or even social rec-
ognition, and work-related community, fairness (i.e., perceived equity in the work-
place), and values (i.e., the conformity of perceived values of the employee and the
organization.
Burnout During the COVID-19 Pandemic
Physicians at the front line of the COVID-19 pandemic have faced unique chal-
lenges, including concern for their personal safety, the welfare of their patients,
families and loved ones, and job stability and security. Healthcare professionals
(HCPs) are responding with selflessness, altruism, and urgency that have unexpect-
edly catalyzed the restoration of some elements of autonomy, competency, and
relatedness [35]. The long-term impact of this experience has yet to be observed.
Current and future burnout among HCPs could be mitigated by actions from health-
care and other governmental institutions, aimed at potentially modifiable factors,
including providing additional training, organizational support and support for fam-
ily, PPE, and mental health resources [36].
Trends in Limiting Burnout
The trend toward viewing physician burnout as a problem of the healthcare organi-
zational culture and working environment has expanded the opportunity for both
physician-directed and systemic or organization-directed interventions to reduce
physician burnout and promote engagement. Engagement has been defined as the
positive antithesis of burnout – characterized by vigor, dedication, and absorption in
work [37]. Organization-directed interventions are more likely to lead to reductions
in burnout, especially those that combine several elements such as structural
34 J. Riches et al.
changes, fostering communication between members of the healthcare team, and

cultivating a sense of teamwork and job control which tend to be the most effective
in reducing burnout [38].
Nine organizational strategies to promote physician engagement have been iden-
tified by Shanafelt and colleagues [37]: acknowledge and assess the problem; har-
ness the power of leadership; develop and implement targeted work unit; cultivate
community at work; use rewards and incentives wisely; align values and strengthen
culture; promote flexibility and work-life integration; provide resources to promote
resilience and self-care; and facilitate and fund organizational science. These strate-
gies are broadly applicable to healthcare organizations, including cancer centers.
Individual resilience is the ability to withstand and recover from stress and
adversity in a healthy, adaptive way [39]. It is not possible to eliminate all the exter-
nal stressors that contribute to burnout, and therefore physicians have a shared
responsibility to build their immunity to stress and ability to tolerate uncertainty.
For optimal performance, however, both the organization and the individual must be
resilient [40]. The Triple Aim (enhancing patient experience, improving population
health, and reducing costs) is a widely accepted approach to optimizing health sys-
tem performance, which is threatened by the magnitude and ubiquity of physician
burnout. It has been suggested that the Triple Aim be expanded to a Quadruple Aim,
adding the goal of improving the work life of healthcare providers, including clini-
cians and staff [41].
Enhanced recognition and understanding of the prevalence and impacts of physi-
cian burnout has resulted in structural changes across many organizations, including
hiring physician and executive chief wellness officers, developing interdisciplinary
steering committees, and enlisting occupational health departments to examine
employee illness and wellness in the context of potentially modifiable workplace
stressors.
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Depression and Substance Use Disorders
in Physicians 4
Martino Belvederi Murri, Marta Gancitano,
Fabio Antenora, Mona Mojtahedzadeh,
and Jaroslava Salman
Introduction
Being a physician can be one of the most rewarding and meaningful professional
paths, but it can also be one of the most demanding and stressful occupations, as
people’s health and lives are at stake. Bearing this responsibility requires a career-
long commitment of expanding one’s knowledge and skill and working within the
boundaries and challenges of the healthcare system one finds oneself in. In recent
decades physicians have suffered a reduced sense of autonomy as a result of the
surge in the administrative workload, concern for malpractice suits, and meeting
business related expectations of today’s commercialized healthcare systems [1–3].
Physicians are in no way immune to mental health disorders, and there is some
evidence that they may have an increased prevalence of common mental disorders,
including depression and anxiety, compared with the general population [4].
Oncologists in particular may be at risk of work-related distress due to the heavy
workload and emotional demands of their specialty (e.g., having to relay bad news,
witnessing more suffering, more frequent patient deaths, and being on the receiving
end of patients’ and families’ anger and blame) [5]. Within the field of oncology,
different specialties may have their unique challenges. For example, at a tertiary
cancer center, medical oncologists often deal with patients with advanced stages of
M. B. Murri · M. Gancitano · F. Antenora

Institute of Psychiatry, Department of Neuroscience and Rehabilitation,
University of Ferrara, Ferrara, Italy
e-mail: [email protected]; [email protected]; [email protected]
M. Mojtahedzadeh · J. Salman (*)
Department of Supportive Care Medicine, City of Hope, Los Angeles, CA, USA

38 M. B. Murri et al.
cancer, and both the patient and the doctor may have less ambitious expectations for
cure. Therefore, patient’s succumbing to cancer may not be as unexpected, although
it is still difficult for everyone involved. On the other hand, in the field of hematol-
ogy-oncology, many diseases have a high potential for complete cure, which ele-
vates everyone’s hopes for having a successful treatment outcome, but the treatment
itself carries a high risk of multiple complications, many of which can be lethal,
thus resulting in the painful crushing of hopes in the event of a patient’s death. In
addition, the day-to-day practice of taking care of patients whose medical condition
can change rapidly and often remains tenuous for a prolonged period of time creates
a level of chronic stress that can take its toll on a physician. Every phone ring, email,
or message in the electronic medical record may trigger anxiety about another
potentially serious issue that the primary oncologist has to address.
Unfortunately, there is a relative scarcity of research on the subject of mental
disorders in physicians, with most of the literature offering primarily self-reported
surveys of specific groups (i.e., medical students, residents, or certain specialties).
Additionally, the majority of research is focused on depression (partly due to
recently increased focus on burnout and suicide in physicians) and substance
abuse. Clearly other kinds of mental disorders can afflict doctors, such as anxiety,
bipolar disorder, attention deficit disorder, obsessive-compulsive disorder, etc., but
the research in those areas is sparse, as far as their prevalence and impact on physi-
cians. Depression remains of utmost concern because, just like in the general popu-
lation, it is responsible for the most morbidity globally, leads to unfortunate
outcomes like suicide, and seems to have biological ramifications (higher rates of
cardiovascular disease, diabetes, accidents) as well as the multitude of psychoso-
cial outcomes (such as divorce, poor relationships, and impact on work perfor-
mance) [6]. Similarly, substance use disorders are as prevalent in physicians as in
the general population, with the added concerns about their impact on patient care
and safety.
Depression
Symptom Versus Disorder
Depression as a descriptor of emotion is common and its causes are usually mul-
tifactorial. The word “depression” is part of our daily vocabulary and as such, its
use is frequent and highly nonspecific. Depression as a symptom may represent
various emotional states, not always pathological in their nature or duration, as
sadness is part of a normal range of human experience. When prolonged or severe,
it may be a symptom of a disorder, such as an adjustment disorder, bereavement,
underlying medical issues, or substance−/medication-induced changes in mood.
In fact, depression often co-exists with a medical illness particularly in patients
older than 60 years, the group also at a high risk for suicide [7]. Distinguishing
these different diagnostic categories may require an expert evaluation and appro-
priate medical work-up.
4 Depression and Substance Use Disorders in Physicians 39
Depression Versus Burnout
There has been a growing body of literature on the topic of physician burnout. A
separate chapter in this textbook addresses the concept of burnout in detail, but we
would like to point out the importance of distinguishing it from clinical depression
while recognizing that the two conditions can certainly overlap and reinforce one
another. Unfortunately, the overlap can lead to mislabeling depression as burnout,
which can result in delayed treatment and prolonged suffering with potentially seri-
ous consequences for the physician’s personal and professional life. Burnout is
situation-specific and driven by a demanding work environment, coupled with
insufficient resources. Given the robust stigma around psychiatric conditions, a phy-
sician may be more likely to conceptualize her or his problem as burnout rather than
a psychiatric disorder [8]. It is important to note that psychiatric disorders, includ-
ing depression, may be an underlying contributor to the development of burnout as
well as a consequence of the unaddressed burnout syndrome. Depression and burn-
out are different, separate constructs, and both may be affected by a negative work
environment, with only burnout improving concomitantly with positive work-
related changes [9]. Depression is a mood disorder caused by underlying biologi-
cally determined psychopathology and, if untreated, will not improve just by work
conditions becoming more favorable [6].
Depression as a Disorder
Major depressive disorder (MDD) is a serious medical illness with known neurobio-
logical underpinnings. Genetic vulnerability, developmental adversity, and various
psychosocial stressors are important variables, triggering and perpetuating the cas-
cade of changes resulting in an actual depressive disorder. The weight of these fac-
tors can vary individually and the presence of protective factors can help mitigate
their impact. By definition a disorder causes clinically significant distress and/or
impairment in social, occupational, or other important areas of functioning.
Both the International Classification of Diseases (ICD 10) and Diagnostic and
Statistical Manual (DSM-5) share the criteria for a major depressive disorder, which
include persistent (1) depressed mood or (2) loss of interest/pleasure lasting for at
least 2 weeks. In addition, during the same 2-week period, four or more of the fol-
lowing symptoms are present:
(3) Significant weight loss or gain or change in appetite

(4) Insomnia or hypersomnia
(5) Psychomotor retardation or agitation
(6) Fatigue
(7) Feelings of worthlessness or inappropriate guilt
(8) Diminished ability to think or concentrate, or indecisiveness
(9) Recurrent thoughts of death
Persistent depressive disorder (formerly known as “dysthymia”) involves

depressed mood for most of the day for at least 2 years. In addition, two or more of
the following symptoms are present: poor appetite or overeating, insomnia or hyper-
somnia, low energy or fatigue, low self-esteem, poor concentration, and feelings of
hopelessness. A reader interested in more detailed diagnostic criteria is recom-
mended to turn to the two commonly used systems in nosology, the DSM-5 [10] and
the International Classification of Diseases (ICD-10) for further information.
Prevalence of Depression Among Physicians
A broad range of workplace factors likely plays a role in contributing to a higher

prevalence of depression and suicidality among physicians. These factors may
include, but are not limited to, large workload, long and irregular working hours,
pressure of patient and service demands, consequences of any errors, poor work-life
balance, and the risk of moral injury if physicians are forced to work in ways that
conflict with their ethics and values [11].
In a cross-sectional study of Austrian physicians, a response to the Major
Depression Inventory (MDI), 10.3% of 5897 participants were found to be affected
by major depression [12]. In a prospective study of more than 1300 male graduates
from Johns Hopkins University medical school, the lifetime prevalence of self-
reported clinical depression was 12.8%, similar to lifetime prevalence of major
depression in US males [13]. The lifetime prevalence for self-identified depression
in female physicians in the Women Physicians Health Study (N = 4501) was 19.5%,
which is a rate similar to that in women in the general population and women pro-
fessionals. Women physicians with a history of severe harassment in a medical set-
ting, tobacco or alcohol abuse, sexual abuse, domestic violence, depression, suicide,
or eating disorders were more likely to report their own attempted suicide or self-
identified depression. It is noteworthy to mention that in this study a higher preva-
lence of attempted suicide was consistently associated with the characteristics also
significantly associated with depression [14]. In comparison cross-sectional rates
(15–30%) of depression in medical students and residents seem to be higher than in
the general population [15–17]. A meta-analysis of studies involving resident physi-
cians yielded a summary prevalence of 28.8%. A secondary analysis restricted to
longitudinal studies found a significant increase in depressive symptoms among
trainees after the start of residency. The median absolute increase in depressive
symptoms among trainees was 15.8% within a year of beginning training [18].
Diagnosis
Depression in physicians may go underdiagnosed, underreported, and inadequately

treated due to a number of factors. Fear of the stigma that views depression or other
mental health issues as a sign of weakness is an important contributor. Other factors
that may impact physicians’ willingness to receive mental health treatment include
fear of licensure suspension, as well as perceived loss of time that one has to spend
on clinical work [19–21]. At the same time, physicians are not always forthcoming
with problems in their functioning [22]. Physicians’ common perception of elevated
knowledge of psychiatric illnesses may also impact the way they receive care,
including self-prescribing [7]. Even when physicians are treated by other physi-
cians, they receive “special” attention, which means that the treating physician often
does not ask about sensitive information, thus perpetuating stigma and ultimately
potentially providing worse care [6]. Physician’s access to confidential and expert
care is essential for successful treatment of clinical depression. The onus is on a
treating psychiatrist to maintain clear professional boundaries while being aware of
potential pitfalls of a colleague-to-colleague countertransference. Maintaining
appropriate level of professionalism becomes much more challenging, if not impos-
sible, when the treating psychiatrist is a personal friend or colleague at the same
institution. Therefore, a physician in need of psychiatric treatment would be well
advised to seek help from a specialist without any close professional or personal ties
predating their treatment.
Impact on Personal and Professional Life
Untreated depression can have significant and sometimes devastating consequences

beyond the individual suffering. These include, but are not limited to, a harmful
impact on one’s ability to function in various roles, including an intimate partner-
ship, parenting, and broader social functions in one’s community and workplace.
Major depressive disorder has one of the highest levels of negative impact on work
outcomes, higher than rheumatoid arthritis, ischemic heart disease, and other mood
disorders, including anxiety [23]. Cognitive dysfunction (e.g., diminished concen-
tration and attention, memory deficits, impairment in verbal learning and word find-
ing, inattentiveness, mental slowing, and executive functioning) is one of the most
common symptoms of MDD. It can lead to a decreased quality of work due to inat-
tention to task details, failure to complete assigned tasks, and/or failure to follow
through on assigned responsibilities. Unfortunately, cognitive dysfunction can per-
sist even after symptomatic remission of depressive symptoms has been achieved
[23]. Several studies have shown that even minor or subthreshold depression
(including dysthymia) is related to poorer work performance. There is a strong lin-
ear relationship between depression symptom severity and the combination of work
loss and productivity impairment [24]. A meta-analysis of seven longitudinal stud-
ies demonstrated that depressive symptoms in physicians are associated with future
medical errors and that medical errors are associated with future depressive symp-
toms in physicians. In other words, the data suggest that the association between
physician depression and medical errors is bidirectional. These findings underscore
the need for institutional policies to remove barriers to the delivery of evidence-
based treatment to physicians with depression [25]. Physicians reporting moderate
to severe depression were two to three times more likely to report substantial impact
on their work, personal roles, and satisfaction compared to physicians with minimal
to mild depression scores. What is even more concerning, these physicians were
also more likely to avoid seeking treatment for their depression due to concerns
about adverse effects on medical staff status or medical licensing and instead would
often cope with their depression by “burying themselves” in their work [20].
Depression during residency was significantly associated with greater presenteeism
(a term referring to working while ill) [26]. Practicing physicians with psychiatric
disorders often encounter overt or covert discrimination in medical licensing, hos-
pital privileges, health insurance, and/or malpractice insurance. It is reasonable to
infer that physician’s concern about disclosure of mental health records is wide-
spread, although studies are lacking [7].
Treatment
Treatment of mood disorders can lead to better physician mental health and produc-
tivity, fewer suicides, and better physical health [7]. However, physicians are known
to be reluctant to seek mental health care. They are actually more likely to self-
prescribe or ask a colleague to provide antidepressants [27]. The frequency with
which physicians appear to self-prescribe antidepressants and feel forced to forgo
mental health care, to seek care in a haphazard or secretive fashion, or to leave their
medical community altogether for treatment is particularly unfortunate and worri-
some. This deserves more detailed study and intervention [21]. A workplace culture
that places a low priority on physician mental health may pose an additional barrier
to care [28].
On an individual level, treatment of clinically significant depression is not differ-
ent from what would be recommended for non-physicians. It generally includes
antidepressants (particularly for moderate to severe forms of depression) and/or
individual psychotherapy. Ideally treatment is based on expert evaluation and tai-
lored to the needs and preferences of an individual suffering from depression. There
is no “one size fits all” treatment approach as there are multiple variables contribut-
ing to the onset and perpetuation of symptoms. For recurrent or treatment resistant
depression, different treatment strategies may need to be employed. Treating to full
remission may be particularly important given the problem of clinical inertia that
depression treatment often poses, that is, lack of follow-up or treatment adjustments
for patients started on antidepressants [24]. A detailed description of various antide-
pressants and psychotherapies is beyond the scope of this chapter.
Substance Use Disorders in Physicians
Mikhail Bulgakov’s 1927 novel Morphine offers a beautiful, yet dramatic account
of the lengths an addicted physician can go before properly asking for help and the
consequences of this reticence. Polyakov, the protagonist, first takes morphine to
ease a gastrointestinal ache and, to his surprise, discovers that not only it is effective
against physical pain but that it also lightens the sufferings of a broken heart. For the
first time in months, he manages to sleep: “I had a good, deep sleep — without any
thoughts of the woman who deceived me.” Morphine, he finds, also provides him
with an “extraordinary clarification of thought and an explosion of capacity for
work.” The rest of the novel describes magnificently his gradual descent into the
deepest recesses of addiction, as he starts hallucinating and gradually withdraws
from his friends and society. The pages of Polyakov’s diary reveal the constant
struggle between self-reproach, regret, and fear, as well as the need to deny how
much of the threat morphine has become to the doctor. Eventually he is able to ask
for help, although he writes to a friend, rather than a psychiatrist, and it is already
too late. This cautionary tale uncovers what may seem a taboo for society: physi-
cians are not immune from substance use and dependence. Descriptively, all the
main elements of addiction are there, especially the difficulty seeking help by
“impaired” physicians.
While being a physician can be fulfilling and rewarding, in fact, the job is also
fraught with heavy responsibilities, intense commitment, and preoccupations that
might lead to high levels of mental distress. In some instances, substance use
becomes a way to self-medicate.
At first glance, literature on substance use among physicians may seem scattered
and relatively scarce, which is unfortunate, especially considering the potential
harms that result from substance use disorders. Inevitably, conducting a study in this
area will meet the same barriers that prevent potential participants from admitting
their problematic substance use and seeking help. Among them, the first and fore-
most is the fear of stigmatization and adverse legal consequences [29, 30].
The landmark study “The Sick Physician: Alcoholism and Drug Dependence,”
promoted by the American Medical Association Council on Mental Health and
released in 1973, was among the first worldwide attempts to acknowledge this issue
in the scientific literature and contributed to lifting the veil on a controversial sub-
ject that was previously unaddressed [31]. Since then, other reports have shed addi-
tional light on this phenomenon, in parallel and thanks to the growth of various
Physician Health Programs (PHPs) [31, 32]. Still, the field might be biased by an
imbalance of a far greater number of studies from the United States, compared with
other countries [31].
Physicians engage in the use of illicit substances and alcohol no less than indi-
viduals in the general population [33–35]. This represents a relevant personal and
societal problem, to the extent that in 2014, the state of California evaluated a prop-
osition that would prompt random testing for alcohol and illicit substance use
among physicians. However, the proposal was eventually dismissed [36, 37]. To our
knowledge, very few studies have addressed the issue of harmful consequences for
patients due to SUDs in physicians. In this regard, it is alarming that patients may
accept to be seen and treated even if they realize the physician is under the influence
of alcohol [38, 39].
Epidemiology
The epidemiology of substance use disorders (SUDs) in a medical profession relies

on limited sources of data. A number of surveys are based largely on self-reported
measures, rather than structured interviews, and only partly allow diagnostic con-
siderations [35, 40–43].
The other main stream of data for research is collected in the context of primary
care providers (PCP), where addicted physicians are treated either by mandate or
spontaneous help-seeking [31, 40, 44–46]. The interpretation of results needs to
take into account the possibility of a selection bias: as expected, surveys yield rela-
tively low response rates (around 20–60% with few exceptions) and may lead to an
underestimation of the problem, whereas reports based on PCP populations may be
affected by the different characteristics of physicians who end up in treatment pro-
grams, in terms of a higher prevalence of SUDs, different patterns of substance use,
and, possibly, a greater tendency to self-disclose [30].
With these caveats, it has been estimated that between 8% and 15% of physi-
cians report having experienced any type of SUD at some point in their lives,
which is usually considered in line with figures from the general population [30,
34, 47–49]. This estimate is mostly due to alcohol abuse or dependence. For
instance, in a recent electronic survey among Danish physicians, 18.3% obtained
a score of 8 or higher in the Alcohol Use Disorders Identification Test (AUDIT),
indicating either hazardous, harmful, or dependent alcohol use [42]. A similar
figure (15.3%) was detected within a survey of US physicians [35], while even
greater estimates (20–25%) were detected in studies from Germany or Japan [41,
43, 50]. Male physicians in particular, as well as physicians in rural areas and
older professionals, might be at a higher risk for alcohol abuse [51]. Likewise,
with few exceptions, alcohol fares as the most used substance among help-seeking
physicians, especially of older ages, possibly because of its widespread legality
around the globe [31]. For instance, among physicians enrolled in various state
Physician Health Programs (PHPs), alcohol was the primary substance of abuse
(50.3%) [44].
Younger doctors, students, or residents may be more prone to using cannabis,
especially in the wake of anti-prohibitionists initiatives in several countries [34].
Estimated rates of prevalence of use of other substances, including cannabis, stimu-
lants, and opioids, are generally lower, although far more variable. Only a handful
of respondents endorsed having used illicit substances in a recent survey of 920
German physicians [41], while between 1% and 3% reported their use in the United
States [35]. Among physicians receiving treatment for substance use disorders, opi-
oids were the second most used substance after alcohol (35.9%), followed by stimu-
lants (7.9%) and other substances (5.9%). Half of the sample reported having used
multiple substances [44].
Diagnosis
Although the ICD-10 and DSM-5 classification systems are not identical in their
criteria of substance use disorders, they both describe the wide spectrum of the dis-
order, from mild to more severe forms of chronically relapsing, compulsive drug
taking. By definition a disorder implies a problematic pattern of alcohol or drug use
leading to clinically significant impairment of functioning or distress.
Clinical presentation of a substance use disorder in a physician can be subtle and
difficult to recognize, especially from the perspective of colleagues. Signs of use of
alcohol or other substances that are readily cleared from the body might go unno-
ticed even for years, especially considering that physicians may tend to protect their
work performance over other aspects, including social, family, and personal life
[33]. It has been suggested that intravenous drug or opioids use may be more rapidly
progressive, so that a shorter time (i.e., few months) might elapse from the first
abuse to detection [48]. Samuelson and Bryson proposed a series of behaviors and
symptoms that may prompt a clinical suspicion of a problematic substance use from
the perspective of colleagues [48]:
• Mood swings (e.g., irritability, anger, euphoria, and depression)

• Withdrawal from acquaintances, reduction in leisure activities
• Increased time spent at work
• Volunteering for extra calls
• Avoiding contact with colleagues
• Frequent bathroom breaks
• Increased quantities of narcotic prescriptions
• Physical changes
Some of these behaviors are correlated with a tendency to self-prescribe or

directly access drugs with an addictive potential; hence few of these behaviors can
be generalized to non-prescription substances, such as cannabis, alcohol, or street
drugs [32, 34].
Chronic use of substances of abuse has been associated with numerous brain
abnormalities, including structural and functional changes across different cortical
areas involved in executive functioning and cognitive, emotional, and behavioral
functions. The nature of a resulting cognitive impairment largely depends on the
substance of choice and has been recently indicated as an additional subtle detri-
mental feature among physicians who suffered from a substance use disorder [52].
The issue of psychiatric comorbidities (e.g., depression, anxiety, bipolar disor-
der, personality disorder) is particularly relevant for a significant number of physi-
cians with SUDs, increasing the likelihood of persistence of both disorders, as well
as risk of unsuccessful treatment [34]. Some studies indicate that about 50% of
physicians, particularly females, with a SUD were affected by a clinically signifi-

cant additional mood or anxiety disorder [30]. The relative lack of longitudinal
data prevents us from the full understanding of the causal relationship between
these disorders. Several surveys detected meaningful associations between sub-
stance use and burnout, depression, and suicidal thoughts [32, 35]. Indeed, the
most common comorbidity identified by studies is of alcohol misuse and affective
disorders [34].
Across different specialties, substance use disorders may vary in terms of the
“drug of choice.” Anesthesiology has been indicated as the field which is most fre-
quently haunted by substance misuse [48]. Although anesthesiologists comprised
about 3% of physicians, their prevalence reached 13% among those who were
treated for SUDs [47]. A study of 44,612 anesthesiology residents, between 1975
and 2009, showed rates of SUD as high as 0.86% during training, with most com-
mon substance category being intravenous opiates. The same study underlined an
important risk of relapse (43% by 30 years after the initial episode) during follow-
up, pointing toward persistence of risk after the completion of training [49]. Opiates,
propofol, and ketamine have been indicated as the most used agents, followed by
inhalational agents and benzodiazepines [48]. A better knowledge and availability
of prescription drugs in these categories may explain these findings [34, 35, 44].
Other fields of medicine seem to present with higher rates of SUDs as well, includ-
ing emergency medicine, psychiatry, surgical specialties, dermatology, and primary
care, whereas pediatricians and internists tend to present with lower rates of sub-
stance misuse [34, 35, 44]. Existing studies also suggest differences in the choice of
the substance: emergency doctors have a higher tendency to use illicit drugs, while
psychiatrists gravitate toward benzodiazepines [48].
Risk Factors
Available studies have attempted to highlight possible risk factors that may help to
identify or prevent SUDs, specifically among physicians. The diversity of popula-
tions in terms of source, specialty, and type of substance use may explain the incon-
sistencies of findings reported by different studies. In two recent surveys on
physician alcohol abuse, the peak of heavy drinking habits was evident among
males in their 60s or younger females; heavy drinking was also associated with
insomnia, cigarette smoking, and working in a countryside [50, 51]. Other studies
have found younger age to be associated with alcohol use [35]. Among help-seeking
groups, there seems to be a relatively greater prevalence of women [53]. Having a
comorbid psychiatric illness, prior history of substance use or treatment, as well as
family history of substance use disorders seems more common among physicians
with SUDs, similar to the rates of these factors in the general population [48].
Personality traits of perfectionism, high self-criticism, and low self-esteem are also
common, as well as tendency to deny emotional needs or stressful life conditions
[32, 34, 44, 48, 54, 55]. Besides having easier access to controlled substances in a
workplace, particularly opioids [44], other characteristics of the work environment
may facilitate the onset or relapse of SUDs in physicians: high job demands, work-
home imbalance, and occupational distress, particularly within highly competitive
environments [32, 34, 48].
Treatment
The experience of Physician Health Programs (PHPs) shows that, when appropri-
ately treated, physicians with substance use disorders can recover and return to
work, even better, on average, than individuals in the general population [34, 44, 46,
52, 56]. On the other hand, the decision to seek treatment is often rejected or delayed
on the grounds of self-misdiagnosis or attempts to self-medicate, sometimes up to
6–7 years since the onset of a problem [34]. Refusal to seek help is often based on
denial or fear of stigmatization. This may entail a failure to recognize having a prob-
lem with substances or, even if the problem is acknowledged, unwillingness to take
action [30]. Denial may take the form of underestimation, or elaborate rationaliza-
tions, especially among physicians who display traits of perfectionism, persever-
ance, and independence – essentially the same traits that might have been adaptive
to reach professional accomplishments in the past but may now hinder the accep-
tance of a patient role in the present, because of shame and other negative feelings
brought about by the stigmatization of SUDs [30, 57–59]. Many physicians view
help-seeking as linked with negative consequences in their profession, including the
possibility of disciplinary hearings, suspensions, malpractice lawsuits, or even
license withdrawal, which might sometimes happen but is much more unlikely
among those who adhere to a treatment program [30, 44, 60]. Unfortunately most
physicians seem to mistrust colleagues regarding their ability to keep confidential-
ity, especially where reporting is mandatory. Asking for help is feared to feed rumors
and derision, although the results of a recent survey seem to reveal more empathic
views by professionals [61]. Finally, treatment can be delayed by fear of potential
familial, social, and economic repercussions, as well as by perceived loss of status
or by equating help-seeking with a sense of personal failure [30, 34, 48].
Knowledge of the therapeutic approaches and outcomes of SUDs in physicians
is largely derived from the experience of PHPs in the United States, particularly by
the Blueprint study [31, 40, 44]. Despite high variability in the provision and strate-
gies of care, PHPs have been established in the majority of US states [32]. Similar
initiatives have been developed in other countries such as Canada,1 Australia,2
United Kingdom,3 Italy,4 Spain,5 Norway [62], Switzerland,6 and others [63]. The
Federation of State Physician Health Programs has recently issued specific
1
https://www.cma.ca/physician-health-and-wellness.
2
http://www.vdhp.org.au/website/home.html.
3
http://sick-doctors-trust.co.uk/; https://www.dsn.org.uk/; https://www.practitionerhealth.nhs.uk/.
4
https://www.ctstorino.com/helper.
5
https://www.fpsomc.es/paime_fott.
6
https://remed.fmh.ch/en/.
guidelines for treatment of SUDs.7 A detailed description of treatment strategies is

outside the scope of this chapter, but in short, they all serve two main functions of
PHPs, namely, protecting patients and rehabilitating physicians [31]. Treatment
principles include the following: immediate response and highly confidential treat-
ment, specialized treatment setting and staff, peer-group therapy, long-term follow-
up program (usually around 5 years) with random drug testing, family involvement,
plans for reentry into practice, advocacy, and relapse contingency plans [31, 34].
The treatment of physicians with SUDs generally starts either with residential (69%
of patients in a recent study) or intensive day treatment programs (31%) followed by
less intensive outpatient visits [40]. Treatment programs may include participation
in community recovery support groups such as caduceus groups, Alcoholics
Anonymous, and Narcotics Anonymous, which have been positively appraised by
participants and have generally positive outcomes [64]. Overall, after 5 years of
care, the vast majority (78%) had all negative drug or alcohol screening test results
and were reinstated to practice (72%), with no differences according to physicians’
specialty [31, 32, 40, 46, 56, 65, 66]. Moreover, the relapse rates for substance abuse
have been estimated as two to three times lower than in the general population,
although they tend to be higher among those with major opioid use, dual diagnosis,
and family history of substance use disorders [51, 65, 67]. The experience of PHPs
suggests that structured, long-term programs may produce good clinical outcomes
and return to work, although help-seeking represents the most difficult step for
many affected physicians.
Conclusion
Mental health disorders in physicians are common but often underdiagnosed and
untreated. There are many important variables contributing to the prevalence of
these disorders and potential barriers to their treatment. Physicians themselves are
frequently reluctant to seek help. When untreated, mental health disorders can have
a profound impact on a physician’s personal and professional functioning.
Promoting and supporting proper self-care should be considered a professional
imperative on an individual, institutional, and societal level. Within the healthcare
setting, any effective strategy to enhance physician well-being must be multilayered
and supported by the institutional stakeholders, as well as embraced by physicians
themselves. Institutional leaders should emulate desired wellness behavior, leading
by example. A resilient and satisfied workforce will be best equipped to care for
patients. It is important for healthcare institutions to develop systems and resources
to promote wellness for employees. The expenses and effort to address this issue
can be offset by decreased cost in turnover, recruitment, and training of new staff
[68]. Above all, patients need their doctors to be healthy in order to receive reliably
effective, safe, and compassionate health care.
7
See also https://www.fsphp.org/ and https://www.idaa.org/.
Acknowledgement Special thanks to Dr. David Snyder at City of Hope, Los Angeles,
California, USA.
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Suicide and Suicide Risk in Physicians
5
Isabella Berardelli, Sally Spencer-Thomas, Luca Germano,
Andrea Barbetti, and Maurizio Pompili
I ntroduction: Burnout and Compassion Fatigue

Among Physicians
Burnout is defined as a state of vital exhaustion and is included in the International

Statistical Classification of Diseases and Related Health Problems (ICD-10) under
the section “problems related to life-management difficulty.” The term “burnout”
was first introduced by Herbert Freudenberger in 1974 after observing several
symptoms, including emotional distress and psychosomatic symptoms, in clinic
employees in the United States. Freudenberger [1] defined burnout as a syndrome
characterized by “excessive demands on energy, strength, or resources” in the work-
place that includes different symptoms, such as malaise, fatigue, frustration, cyni-
cism, inefficacy, and hopelessness. Subsequently, Christina Maslach, a social
psychologist, described job burnout as a syndrome comprising different features,
including emotional exhaustion, cynicism, depersonalization, and low personal
accomplishment or efficiency in different types of workers, thus highlighting a con-
nection between emotional alterations and job stressors [2].
Burnout syndrome typically manifests in employees working in service occupa-
tions, such as healthcare, that are marked by a high degree of interpersonal contact.
I. Berardelli · M. Pompili (*)

Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and
Psychology, Suicide Prevention Centre, Sant’Andrea Hospital, Sapienza University of Rome,
Rome, Italy
S. Spencer-Thomas
United Suicide Survivors International, Denver, CO, USA
L. Germano · A. Barbetti
Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sant’Andrea
Hospital, Sapienza University of Rome, Rome, Italy

56 I. Berardelli et al.
Additionally, the syndrome appears to be prevalent in professionals who have a high

degree of perfectionism and feel guilty if they are not performing up to their
expected standards [3]. The syndrome has been observed in physicians, nurses,
social workers, therapists, and a variety of other healthcare workers.
A related concept to burnout is the experience of compassion fatigue [3–5].
Compassion fatigue has been described as the lost ability to care subsequent to a
“snowballing process” of relationship and moral distress that impacts caregivers
working to serve high-need people [3, 4]. Compassion is central to the practice of
medicine; the desire to help alleviate others’ suffering is the main reason many
choose the profession [5]; thus, loss of this capacity often results in frustration,
avoidance, and general emotional numbing [3].
In an effort to delineate these two concepts, researchers [3, 4] have noted that
burnout tends to be more connected to environmental factors like mismatches in
expected workload, autonomy, rewards, values, and fairness, while compassion
fatigue seems more connected to interpersonal stresses related to observing continu-
ous suffering (Fig. 5.1).
The rate of burnout among physicians is alarming [6]; over half of physicians in
the USA have symptoms of burnout at some point in their career [7]. Indeed, while
protective factors in the general population include higher levels of education and
professional degrees, one notable exception to this is the medical degree, which
seems to increase risk. Physicians working on the front lines of healthcare, including
in specialties such as oncology, anesthesiology, emergency medicine, family medi-
cine, internal medicine, and obstetrics/gynecology, are at an especially high risk of
Environmental & Institutional Factors
Qualities of the
Qualities of the
patients & their
physician
Families
Qualities of the
clinical Work
Compassion Satisfaction Compassion Fatigue
Physician Burnout
Fig. 5.1 Model of physician burnout. (Adapted from [4, 5])

5 Suicide and Suicide Risk in Physicians 57
burnout [7]. Burnout appears to be more frequent in females than males [8, 9] and is
conceptualized as a physical and mental response that arises in relation to chronic
occupational and interpersonal stressors and continues over a period of time. Indeed,
Dyrbye et al. [10] found that although the types of stressors may change for physi-
cians over the course of their career, work-related stress was a continuous feature of
the profession. Burnout syndrome may develop slowly over the course of a year,
beginning with mild and subthreshold symptoms such as tiredness and a lack of
energy that are often followed by more disabling physical, emotional, and psychic
symptoms [11] that may occur alone or in combination with other clinical presenta-
tions. Physical symptoms include chronic fatigue, cardiovascular issues, cognitive
dysfunction, insomnia, and gastrointestinal complaints, while emotional symptoms
mainly include anger, depressive symptoms, anxiety, and depersonalization.
The presence of burnout symptoms can undermine physicians’ professional
development and can contribute to carelessness, a lack of commitment, increased
risk of error, and additional risks to patients.
The worst consequences of burnout and compassion fatigue include depersonali-
zation, i.e., the treatment of patients as objects rather than human beings, altered
clinical relationships with patients, a sense of inefficacy, decreased work productiv-
ity, dissatisfaction, and a higher risk of professional error [12]. Furthermore, the
persistence of a difficult and exhausting work situation contributes to the develop-
ment of exhaustion or cynicism, which in turn decreases physicians’ sense of effec-
tiveness. Burnout syndrome also puts physicians at risk of developing other
psychological and psychiatric disorders, including depressive and anxious symp-
toms, alcohol abuse, drug dependence, and suicidal risk [13]. A growing amount of
literature has stressed the impact of burnout on patient satisfaction, physician-
patient relationships, and healthcare outcomes. Research findings have emphasized
the link between physician burnout and both job satisfaction and patient satisfac-
tion, between job satisfaction and patient satisfaction, and between job satisfaction
and patient-reported adherence to medical advice [14]. Occupational stress also
negatively impacts physicians’ work performance, reduces the quality of patient
care [15], and influences work absences due to sickness [16] and the decision to
leave the profession [17].
From an etiopathogenetic point of view, burnout is not caused by a single factor.
Like many other syndromes in traditional medicine, a multifactorial model may bet-
ter explain the manifold causes of this very high prevalence in physicians. Several
studies have proposed a model of burnout development in which personality and
environmental factors play a role and exert varying degrees of influence at different
stages of the burnout process [18]. Burnout models generally evaluate the influence
of job demands, requests, and available resources that are stressors or moderate the
stressor-strain relationship. Several external factors are implicated in the genesis of
burnout syndrome among physicians, including the loss of autonomy (e.g., the abil-
ity to decide when to see patients and the amount of time to spend with each patient),
medical and administrative rules, intense feelings of powerlessness (especially in
physicians who work with populations in poor socioeconomic situations), work
organization, financial issues, interference with family and social life, relationships
with colleagues and patients, and work demand (long hours, workload, and
Table 5.1 Risk factors Risk factors for burnout

for burnout Junior physicians: Oncology fellows, physicians
≤ 5 years from training completion
Single, unmarried/nonpartnered physicians
Personality characteristics: Compulsiveness,
extraversion, type A behavior
Increased time in direct patient care
High occupational demands
Lack of control over daily tasks
Increased administrative responsibilities
Use of electronic medical record systems
Limited decision-making
Unclear job expectations
Lack of social support
Changing healthcare system
Care of patients who are terminally ill with cancer
pressure) [16, 19]. Another heavily researched area evaluates the role of environ-
mental stressors, with one study finding that US physicians spend 2.6 hours/week
complying with external quality measures instead of visiting patients [20], thus
highlighting the amount of time that physicians spend performing administrative
and clerical work. The aforementioned groups of variable factors are important to
investigate because they have an important effect on mental health as it applies to
workplace health. Once clearly defined, these variable factors may be modified to
reduce their impact on the mental health of physicians (see Table 5.1).
Fernando and Consedine [5] also note that physician compassion is not a deplet-
able resource, and rather than tiring, the experience of compassion is often transac-
tional, rewarding, and pleasurable. This positive experience of compassion
satisfaction oscillates with compassion fatigue depending on a number of factors.
Fernando and Consedine [5] observed that compassion (both satisfaction and
fatigue) are the result of the interplay of dynamic influence of the patient and their
families, the nature of the clinical work, and other institutional and environmental
factors and that compassion satisfaction can offset experiences of burnout and com-
passion fatigue.
Of note, several of these risk factors for burnout are also considered psychosocial
hazards for workplace-related suicide [21].
Depression and Suicide Risk Among Physicians
Studies have demonstrated that the prevalence of several mental diseases in physi-
cians is higher than in the general population [22]. The most frequent disorders
among physicians are alcohol use, prescription drug use (minor opiates and benzo-
diazepine tranquilizers) [23], and depression [24], and there is a significantly higher
suicide rate in physicians than in the general population [25].
Table 5.2 Consequences of Patient care

physician burnout Lower care quality
Medical errors
Longer recovery times
Lower patient satisfaction
Physician health
Substance abuse
Motor vehicle crashes
Poor self-care
Depression – Suicidal ideation
Healthcare system
Reduced physician productivity
Increased physician turnover
Less patient access
Increased costs
Although physicians acknowledge that they have burnout symptoms or symp-

toms of a psychological-psychiatric origin, a delay in the request for help has been
noted. Physicians usually deny the existence of their problems [26] because asking
for help could be interpreted by their colleagues and patients as a professional
weakness or disability. The medical profession is generally perceived as a very
stressful occupation, and although some stressors in the healthcare settings cannot
be modified, such as the management of incurable patients or the proximity to
human suffering, there are other variable stressors that are involved in the genesis of
burnout syndrome, compassion fatigue, and depression in physicians. Depression
and burnout syndrome represent significant mental health problems in physicians
that may result in reduced work performance [27, 28]. Consequences of burnout are
reported in Table 5.2.
Depression is a disorder characterized by a change in mood and a loss of interest
or pleasure in daily activities that is sustained over time. It is characterized also by
symptoms related to irritability, anhedonia, weight and appetite change, sleep dis-
turbances, changes in activity, fatigue and loss of energy, feelings of guilt and
worthlessness, problems with concentration, and suicide risk. Several studies have
demonstrated that the risk of depression is higher in physicians than in a comparable
lay population [29]. In a review and meta-analysis of studies describing the preva-
lence of depression and depressive symptoms in medical residency, Mata et al. [30]
found an overall incidence of 28.8%, with a range of 20.9–43.2%. It is notable that
the prevalence increased significantly over the course of the first year of training and
progressively in subsequent years. Recent meta-analyses of global studies estimate
an overall prevalence of 27% in medical students, 29% in residents, and up to 60%
in resident doctors [31]. However, the prevalence of depression in physicians is dif-
ficult to accurately assess due to wide variations in diagnostic measures and large
differences in depressive symptoms between countries and medical specialties.
Since only 35% of physicians have a regular source of healthcare, depression may
be under-recognized in this population as compared to other professions. Although

depression may affect anyone, the risk is increased by genetic predisposition, early
traumatic life events, later bereavements, illnesses, relationship breakdowns, pov-
erty, unemployment, and problems caused by substance use.
Stress as a precipitating factor for depression is an important feature, especially
in physicians. Causes of work stress may vary among different medical specialties:
family practitioners may face increased primary care demands coupled with shrink-
ing resources, while emergency care doctors and oncologists may suffer elements of
posttraumatic stress [32]. Because many have dedicated a significant part of their
life to developing the skills and status of a physician, many form a “single source
identity” around their profession. Whenever anything threatens this identity – com-
plaints, poor health, or conflicts – the “fall seems so great.”
While personal attributes generally ensure patients are well cared for, they also
increase physicians’ risk of developing mental health problems. Conscientiousness,
obsessiveness, and perfectionism may be more common in doctors, perhaps leading
to rigidity, over-commitment, self-criticism, and an inability to unwind and replen-
ish their inner resources. An inflated fear of making mistakes and a sense of dimin-
ished patient care may result in physicians experiencing overwhelming feelings of
guilt, failure, shame, and low self-esteem. Failure to cope, coupled with the signifi-
cant stigma that accompanies mental health problems, may dissuade many from
disclosing their depression.
Suicide is best understood as the tragic result of multifactorial factors, including
individual health, behavioral health, and environmental factors. For instance, a per-
son at risk for suicide may have poorly managed mental health conditions, such as
depression and bipolar disorder while also experiencing environmental factors like
divorce, a death of a loved one, and unresolved childhood trauma. While factors like
these are often listed when considering risk factors for suicide, aspects of the work
environment are often overlooked, and in the medical professions, this oversight is
proving to be deadly.
Suicidal ideation is more frequent in physicians who are suffering from signifi-
cant stress, burnout, and depression. Physicians’ suicide attempts are more fatal
than the general population. Suicide risk increases in medical school but dramati-
cally accelerates once trainees enter graduate medical education programs. One
study reported an increase from approximately 4% during the pre-internship period
to about 25% during the internship years. Sen et al. showed that the frequency of
suicidal ideation increased approximately fourfold during the first 3 months of the
internship [33]. Compared with the general population, the relative risk of suicide is
1.4 in male physicians and 2.3 in female physicians. In addition to a higher percent-
age of attempted suicides, physicians also died of suicide at a higher rate than the
general population, in part because of their enhanced knowledge of toxicology and
other suicide techniques. Interestingly, despite a considerably higher risk of suicide
in men than women in the general population, female healthcare workers present
higher suicide rates than men.
Physician suicide rates are not homogenous between all countries, and physician
satisfaction has been reported to differ between different epochs of time (Kalmoe
et al. 2019). Some medical specialties have been suggested to be particularly at risk
of depression and suicide, and several occupational features seem to correlate with
an increased risk of depression and suicide in different medical or surgical special-
ties; trauma and suffering probably contribute in the genesis of suicide risk. A heavy
workload and working hours, including long shifts and unpredictable hours (with
associated sleep deprivation) and situational stress (life-and-death emergencies), are
related to burnout, depression, and suicide risk.
Bringing these concepts together, Joiner’s [34] model of suicide risk helps clarify
how physician experiences of burnout, compassion fatigue, and depression and
environmental factors of medicine are connected to suicide risk. In his book Why
People Die by Suicide, Joiner [34] explains that those who kill themselves not only
have a desire to escape overwhelming emotional pain by dying, they have also
learned to overcome the instinct for self-preservation. The theory states that the risk
of suicide is partly explained by the convergence of three factors: perceived burden-
someness, thwarted belongingness, and capability. Burdensomeness can be experi-
enced by physicians who are experiencing the consequences of burnout (e.g., loss of
self-efficacy or clinical error) and disconnection from compassion fatigue. These
experiences drive the “I want to” part of the suicide risk equation; however suicidal
thoughts without action are common and not fatal; the risk comes from the capabil-
ity for suicide – or the “I can” part of the risk equation. Joiner argues that those who
have the ability to be fearless about suicide are more likely to die by suicide or have
very lethal attempts. The capability for suicide comes from exposure to painful and
provocative life experiences and the knowledge and skills for lethal self-harm
(Fig. 5.2).
Desire for suicide/Escape

overwhelming emotional pain Model of suicide risk
Perceived Burdensomeness I can.
Capability
Thwarted Belongingness
I want High risk for sucide

to. death or serious
attempt
Fig. 5.2 Model of suicide risk. (Joiner [34])

Burnout Among Oncologists
Several medical specialties are considered to be at high risk of psychological stress.

Although burnout and depression among physicians have received increasing atten-
tion, they still remain under-investigated in several medical specialties. Burnout and
depression symptoms are overlapping yet distinct entities, and several medical spe-
cialties seem to be at greater risk of both syndromes. Specialists at the highest risk
are oncologists, anesthesiologists, psychiatrists, general practitioners, and general
surgeons.
Burnout is elevated in oncology, with a prevalence of 25–35% among medical
oncologists, 28–36% among surgical oncologists, and 28% among radiation oncol-
ogists [35]. Environmental, occupational, and organizational risk factors specific to
oncology include increased time in direct patient care, high occupational demands,
a lack of control over daily tasks, increased administrative responsibilities, the use
of electronic medical record systems, limited decision-making power, unclear job
expectations, a lack of social support, and the changing healthcare landscape [36].
Constant life-and-death decisions, the administration of potentially toxic therapies,
long work hours (63 hours/week), reduced work/life balance, and the limited ability
to prolong life for many patients may also contribute to burnout [37]. Physicians
who are dedicated, motivated, or even overinvolved, or who maintain poor boundar-
ies or continuously try to prove their worth probably, are more susceptible to burn-
out even in relation to coping or defense mechanism used.
Many studies have demonstrated the global scale of burnout in medical oncology
among different healthcare systems [38, 39]. In 2005, a survey study by Allegra
et al. of over 1700 oncologists revealed that nearly 62% of oncologists in commu-
nity practice in the USA reported specific burnout symptoms, including the top
three signs: frustration (78%), emotional exhaustion (69%), and a lack of work sat-
isfaction (50%) [Hlubocky et al., 2016]. A more recent study found that 45% of
American Society of Clinical Oncology (ASCO) member medical oncologists have
reportedly experienced emotional exhaustion and/or depersonalization symptoms
related to burnout [37]. In Europe and Australia, burnout rates vary significantly,
ranging from 52% to 78% depending on the medical oncology specialty, practice,
healthcare system, and screening tools used [40]. For example, in France, a mailed
survey study that evaluated 340 medical and radiation oncology fellows using the
Maslach Burnout Inventory found that 44% believed burnout was prevalent and
associated with a low perception of health status and a desire to leave medicine [41].
In Australia, 36% of gynecologic oncologists surveyed reported a high degree of
emotional exhaustion, with 43% reporting a desire to leave their current position,
29% considering retirement, and 57% reporting a desire to reduce work hours [40].
Large-scale studies regarding the incidence and development of burnout are cur-
rently underway, and it is hoped that they will provide important information regard-
ing the identification of risk factors as well as the implementation of individual and
institutional interventions to address this increasingly burdensome phenomenon.
Aside from the high patient volume and other stressors that are common across
many disciplines, oncologists must also work to preserve life, mitigate
complications, and negotiate death. In fact, the latter stressor (dealing with death)
underlies most of the other routine stressors in oncology, as defined by Medisauskaite
et al. [42]. These stressors include dealing with distressed or blaming relatives, cop-
ing with patients suffering during treatment, feeling disappointed about cancer
treatment options, coping with unrealistic expectations about cancer treatment,
delivering bad news, worrying about patients outside of work, worrying about with-
drawal or inappropriate continuation of cancer treatment, and communicating with
crying or distressed patients. Patients are constantly in precarious situations that
require care and attention, and these tasks can become habituated and compartmen-
talized for the oncologist in the service of providing objective information and sus-
taining boundaries. For the most part, oncologists care deeply about their patients,
and this process is not always maligned. However, problems arise when the approach
becomes fixed and physicians do not vary their approach to different kinds of
patients.
A recent study found that oncologists who were involved, or had additional train-
ing, in psychosocial issues in oncology were much less likely to suffer burnout or
experience depersonalization in their practice [37].
Oncology is exciting because of the privilege of working with new and expand-
ing science and helping patients get better, but oncologists remain on the front lines
between life and death. Although this may not be directly associated with burnout
(burnout appears to be more closely linked to work load, administrative tasks, and
professional satisfaction), it contributes to depression and subsequently to suicide.
Today’s death-denying culture may contribute to the loneliness that physicians feel
in their work. In addition, the higher the mortality salience of the patient situation,
the more likely it is that communication and empathy may suffer, which may partly
explain why oncologists historically have a difficult time guessing the distress levels
of their patients or their current psychological states [37]. This may also explain
why communication skill training is vital for oncologists. At the same time, the high
risk of errors and other consequences of decisions can lead to moral injury, and all
these factors can weigh heavily on the oncology work environment.
Burnout and Suicide Risk Among Other Medical Specialists
Anesthesiologists also have a high risk of suicide, which may be due to easy
access to potentially lethal drugs, a high prevalence of burnout, a high workload
with fear of harming patients, organizational burden, poor autonomy, and con-
flicts with colleagues. In a study of approximately 1500 anesthesiology residents,
De Oliveira et al. [43] found a burnout risk of 41% in trainees. Burnout predictors
included female sex, more than 70 work hours/week, and the consumption of
more than five alcoholic drinks per week. A Canadian study on the well-being of
interns and residents indicated that significant stressors, including financial debt,
were present at a high level in a third of trainees and that 18% of the trainees
studied reported their mental health to be either fair or poor. The demands of con-
stant vigilance and the acuity and significance of decision-making are other
elements of anesthesiology practice that create stress for many practitioners [44].
In addition, the relative isolation in which most anesthesiologists work also con-
tributes to stress. The nature of the intraoperative environment and the practice of
anesthesiology make it difficult to have ongoing discussions, consultations, and
collaboration. Staffing patterns do not include easy backup plans and there is a
culture of reluctance to ask for help. These factors can create situations in which
anesthesiologists continue to work following a poor outcome or challenging case
rather than calling a peer to allow time for debriefing, counseling, or recovery
from the event [44]. The isolated aspect of anesthesiology residency training and
practice decreases the ability of these practitioners to compare experiences and
performance with colleagues, which can lead to inappropriate feelings of low self-
esteem and decreased confidence. These factors, plus easy access to drugs that can
be diverted and abused, convey particular risk to practicing anesthesiologists and
trainees and may confound the reporting and incidence of attempted and com-
pleted suicide in the anesthesiology community. The topics of drug diversion and
substance abuse are beyond the scope of this article but are addressed elsewhere
in this issue of the journal.
Other medical specialties at high risk of burnout or suicide include psychiatrists,
general practitioners, and physicians dealing with life-and-death emergencies [45].
For psychiatrists, the high risk of suicide has been linked to stressful and traumatic
experiences, including the suicides of patients. For general practitioners, moral
loneliness, job interferences with family life, constant interruptions both at home
and at work, increasing administrative constraints, and high patient expectations
lead to low job satisfaction and poor mental health [46]. Physicians and surgeons
involved in life-and-death emergencies are also under a high degree of stress [14].
It has been shown that intraoperative death increased the morbidity rate for patients
operated on by the same surgeon in the subsequent 48 hours, with this rate being
more pronounced when the death occurred during emergency surgery [47].
Furthermore, burnout also plays a role in the development of major depression and
substance abuse. With this context, it is easy to understand why physician burnout
may seriously affect job performance and well-being, as well as the quality of
patient care.
Conclusions and Recommendations
To implement coordinated and synergistic preventive strategies, we need to both

identify physicians with mental health conditions and how our workplace environ-
ments may be driving burnout, compassion fatigue, and suicidal despair [48]. The
high risk of suicide in physicians might be explained by several putative factors
such as the psychosocial work environment or specific personality traits of physi-
cians. Literature has shown that psychosocial work environment, including conflicts
with colleagues and a lack of teamwork and social support, is an important risk
factor. Physicians must also routinely communicate bad news and are in frequent
contact with illness, anxiety, suffering, and death. Perfectionism, compulsive
attention to detail, an exaggerated sense of duty or responsibility, and the desire to

please everyone are strengths in the workplace, but increased stress and depression
may trap physicians in a vicious cycle without seeking help. Physicians may refuse
to ask for help because of professional culture. For some medical specializations,
given the enormous emotional load related to the type of profession, it therefore
seems necessary to offer psychological help and support services. In conclusion
identifying the first symptoms of burnout seems essential to be able to identify the
health personnel who are beginning to manifest a psychological discomfort inherent
in their work activities. Additionally, medical environments might take a more pro-
active public health approach to reduce burnout and compassion fatigue and sui-
cidal despair [4]:
• Provide opportunities for building stronger relationships with colleagues/

classmates.
• Offer emotional intelligence training to help with emotional awareness and regu-
lation in self and others.
• Develop mentoring partnerships to allow more tenured physicians to help buffer
the burnout of newer physicians.
• Design supervision and promotional recognition and reward strategies that iden-
tify physicians practicing self-care and empowering other physicians to do
the same.
• Identify and resolve mismatches in expectations in workload, control, and values
between physicians and their administrators.
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Screening and Assessment of Burnout
with a Focus on Oncology Healthcare 6
Providers
Emily Kantoff, Konstantina Matsoukas, and Andrew Roth
Introduction
Early identification of burnout is essential because burnout can have deleterious

effects on both clinicians’ health [1–10] and the quality of care delivered to patients
and families [3, 11–17]. Therefore, it is fundamental to have accurate and reliable
methods to measure and assess burnout. Accurate screening and assessment of clini-
cians can help in directing organizational policies to cultivate clinician well-being
and improve the care provided by health organizations. This chapter will explore
some of the associated factors that may help distinguish oncology clinicians at risk
of developing burnout. The chapter will also examine some of the established
screening tools that have been used during the assessment of healthcare profession-
als within the literature, as well as look at the benefits and risks of using each of
these tools.
E. Kantoff (*)
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center,
New York, NY, USA
K. Matsoukas
Medical Library, Memorial Sloan Kettering Cancer Center, New York, NY, USA
A. Roth
New York, NY, USA
Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA

70 E. Kantoff et al.
Background and Rationale for Focusing on Oncology Providers
Attention to burnout in oncology healthcare providers has increased over the last
few decades [18] as the practice of medicine in general, and oncology in particular,
has changed [19]. Historically oncologists had more autonomy, often in their own
practices, than they do today. The trend has shifted to that of being employees in a
new world of electronic medical records, with less control over daily and weekly
schedules, organization of working hours, and the balance between clinical and
administrative duties, as productivity expectations are increasingly set by hospital
administrators based on financial metrics. Oncology providers have always been at
increased risk of burnout because of their responsibilities to care for patients with
an increased likelihood of significant acute and chronic illness, suffering, and death
and thus chronically dealing with grief and loss. Moreover, they work long hours
and supervise the administration of highly toxic therapy [20].
The spotlight on distress and burnout has become even more acute in the tragic
explosion of patients who face not only the perils of a cancer diagnosis but the new
scourge of the COVID-19 virus pandemic. The pandemic has demanded more work
hours, more risk of personal well-being while caring for others and watching col-
leagues of all oncology specialties fall ill to disease as a soldier might fall in the
battlefield, less individual and family leisure time, and more patient morbidity and
mortality than is often at the foundation of a rigorous career in oncology [21].
Burnout has been studied in many health caregiver specialties with general burn-
out instruments, as well as long and short item measurements, and has been linked
to significant implications or outcome measures for patient and healthcare provider
well-being [22–24]. Various specialty providers and levels of employees that have
been studied for prevalence and impact of burnout have included, but are not limited
to, physicians [20, 25], physician assistants [26, 27], nurses [28, 29], medical train-
ees [30], and even premedical students [31].
Constructs such as empathy that may impact burnout in medical residents rotat-
ing on oncology units have also been studied both in the United States [32] and
internationally [33, 34] and affect a large proportion of oncologists in particular
[35]. Burnout has been identified in the cancer setting in a number of varied special-
ties including surgery [25, 36], pediatric oncology [24, 37, 38], and radiation oncol-
ogists [39].
Associated Factors that May Influence Burnout
Previous studies highlight that many personal and professional factors can either
aggravate or protect clinicians against the development of burnout. The construct of
burnout is a multifaceted heterogeneous construct; therefore developing risk pro-
files during assessment could perhaps be helpful [40, 41]. Nonetheless, the current
literature differs in their conclusions related to these risk factors; therefore, these
variables should be studied more meticulously before they can be generalizable to
actual clinical interventions for oncology staff at this time [29]. Nonetheless,
6 Screening and Assessment of Burnout with a Focus on Oncology Healthcare… 71
exploring these associated variables as they pertain to oncology staff can perhaps be
helpful when trying to assess which clinicians may be at higher risk for the develop-
ment of the syndrome within an institution.
ome of the Professional or Occupational-Related Variables

S
Associated with Burnout
A perceived lack of control, lack of social support, or lack of clearly delineated job
expectations have been linked to burnout [42]. For instance, lacking autonomy or
the ability to influence decisions that affect one’s job, such as one’s schedule, tasks,
or access to available resources (e.g., support services, training, or ability to request
leave), is associated with burnout within the literature; such occupational variables
can lead clinicians to feel a sense of helplessness or endorse work-associated stress
[28, 29, 42–44].
Some studies even show that accessible professional support services, supervi-
sion, and skills training programs where clinicians feel understood and feel they are
able to learn and cultivate new skills can be protective against burnout [29, 45–50].
Thus, limited interprofessional relationships or opportunities for advancement
can increase burnout; hence, an organizational climate where leaders mentor and
recognize strong work can also protect against burnout [50–52]. Furthermore, pro-
fessional support is essential, as isolation and unsociable shifts within the work-
place have also been linked to burnout [42, 53]. Payment models seem to influence
burnout also, with salary-based models leading to less burnout than incentive- or
performance-based models [20, 52]. Institutional culture can also contribute to
burnout, for instance, the nonuse of offered annual leave can negatively influence
clinician well-being [25]. Work inefficiency due to clerical burden, lack of non-
physician staff support, and electronic medical record requirements can increase
burnout [52, 54]. Lastly, burnout is linked to job conditions with extremes in activity
(when the job is monotonous or highly emotionally taxing) or extremes in workload
(where clinicians feel burdened by excessive tasks, or are required to work long
hours, or take weekend or overnight calls) [29, 41, 42, 47, 52, 55, 56].
ome Personal Characteristics or Individual Lifestyle Factors

S
Associated with Burnout
Gender does not seem to wield a substantial influence on the development of burn-
out, and theoretically both men and women can experience burnout comparably [29,
56–58]. Therefore, gender is not an independent predictor of burnout [52]. However,
within the literature there are trends that indicate women tend to experience more
emotional exhaustion as men tend to experience more depersonalization, but this is
not consistent in all studies [46, 56, 59].
Age similarly does not seem to cause significant influence on the construct of
burnout and has conflicting information within the literature. For instance, one
systematic review [29] revealed that younger oncology nurses experienced less
emotional exhaustion in studies [60, 61], whereas it found EE more prevalent among
those oncology nurses older than 40 years [28]. Nonetheless, it recognized that this
association did not hold up in all of the studies [29, 58]. However, some studies
show that younger physicians (less than 55 years old) have almost double the risk of
burnout symptoms in comparison to their older counterparts (those older than
55 years old) [35, 52].
Personality features and interpersonal skills are also possibly linked to burnout
[52]. For instance, one study found that oncology nurses with high levels of neuroti-
cism and low levels of friendliness and responsibility were more likely to develop
burnout [62]. Having kids younger than 21 years old is associated with increased
risk of burnout symptoms [32]. In a meta-analysis, burnout among oncologists was
also found to be associated with being single, reduced psychological well-being,
and difficulties outside of work [35]. Lastly, achieving a perceived work-life bal-
ance and individual utilization of vacation time can be seen as protective factors
against the development of stress and burnout [36, 46, 63].
Summary of Established Tools and Survey Instruments

A
to Measure Work-Related Dimensions of Burnout
aslach Burnout Inventory-Human Service Survey for Medical

M
Personnel (MBI-HSS)
The MBI is the gold standard for accurate measurement of burnout most commonly
found within the literature. Newer tools evaluating burnout are most commonly
compared to this benchmark barometer instrument. The measure was released in
1981, originating from US researchers [64].
Format It is a 22-item self-administered questionnaire. The MBI has three sub-

scales to evaluate the following domains:
1. Emotional exhaustion (EE): the state where “as emotional resources are depleted,
workers feel they are no longer able to give of themselves at a psychological
level” [30].
2. Depersonalization (DEP): the development of callous, negative, or dehumanized
perceptions and feelings toward others.
3. Personal accomplishment (PA): the tendency for workers to assess themselves
positively in competency levels of dealing with patients and feeling fulfilled by
work [65, 66].
Each subscale incorporates several queries with frequency valuing selections of

the following: never, a few times a year or less, once a month or less, a few times a
month, once a week, a few times a week, or every day [64, 65].
Data Analysis Researchers frequently categorize outcomes into burnout versus

non-burnout categories, but unfortunately there is no acknowledged standard defini-
tion provided by the developers of the instrument. The manual elucidates that the
dimensions are established by factor analysis as three distinct and different dimen-
sions. Therefore, it is favored to assess links with subscale scores as continuous
variables and outcomes can be looked at separately [40, 64, 65].
Moreover, there has been some controversy over which domain subscales are to
be included as most important in the analysis. A frequently utilized method consid-
ers healthcare workers as presenting with at least one symptom of burnout if they
have either high EE (greater than or equal to 27 on this subscale) or high DEP
(greater than or equal to 10 on this subscale) [20, 55, 64, 67]. Traditionally, although
DEP can often get linked to the worst outcome measures of burnout, EE is consid-
ered to commonly be viewed as the most important subdomain of burnout within the
literature; thus, analysis of only one subdomain of burnout can be incomplete when
considering adequate screening [52]. Relatedly, some evidence indicates that ele-
vated scores on these subscales can differentiate clinical burnout from the non-
burned out, and some studies even make burnout scores related to only those two
domains [20, 64]. Some scholars argue that EE and DEP are thus the core burnout
dimensions, while lowered PA appears to develop in parallel [55, 68]. Nonetheless,
other studies take into account all three domains and consider healthcare workers to
have burnout if they have a high EE score plus either a high DP score or a low PA
score (PA score less than 33) [40, 46, 64, 69].
Limitations of MBI-HSS [64, 70]

1. The results necessitate statistical resources and expertise to analyze and there-
fore are moderately complex to evaluate [64]. It does not produce a single burn-
out score but three separate scores for each subscale that can be evaluated
separately or in correlation to the other subscales. Thus respondents’ scale scores
can be interpreted differently [64, 70]. For instance, there is not a clear consen-
sus on which subdomains are needed, cutoffs for subdomains are arbitrary, and
some scholars bring up that subdomains could perhaps be adapted to account for
social and cultural differences in varying populations. Also, the results are based
on a single source of information, and thus self-reported measures could affect
statistical analysis and do not denote casual relationships [55, 70, 71].
2. It consists of 22 items; therefore it takes between 10 and 15 minutes to fill out
and might be too lengthy for routine use if an institution wants to limit responder
burden [41, 70].
3. The test is not free and has an associated cost per administration.
4. May not be sensitive to change within a short timeframe [70].
5. Applicable only to healthcare professionals who work with patients directly.
However, for those without direct patient contact, the assessment could instead
use the general version of this tool: MBI-GS.
Benefits of MBI-HSS [64, 70]

1. Standardized instrument validated and most widely used in published burnout
literature and research. With the strongest construct validity evidence in physi-
cians and other healthcare professionals with direct patient contact (including
physicians, residents/fellows, medical students, nurses, and social workers)
[64, 70].
2. Measures burnout as defined by the World Health Organization [72]. With
national benchmark data (results in national samples of healthcare professionals,
which aids in offering a context for interpreting results), psychometrics, and
robust empirically driven literature showing that results correlate with actionable
outcomes of importance to stakeholders such as patient satisfaction [73], medi-
cal error(s) [15, 64, 70, 74, 75], and healthcare worker turnover and absenteeism
[9, 64, 70, 76, 77], as well as improper, illegal, or negligent professional activity
[64, 70, 78].
3. Translations are available in multiple languages and have been utilized in both
domestic and international research.
4. The only tool that currently has empirical data supporting it can uncover sensi-
tivity to change within longer timeframes and can identify meaningful effect
sizes from interventions [64, 70, 79].
Shortened Two-Item MBI-HSS
This is a concise adaptation of the original MBI-HSS, created in the United States
by West and colleagues [80] to serve as a snapshot measure of burnout.
Format Self-administered two questions adapted from the full MBI that focus on
the assessment of EE and DEP. EE is assessed using the question: How often do you
feel burned out from your work? DEP is assessed using the question: Have I become
more callous toward people since I took this job? Each of these queries is answered
on a 7-point Likert scale, whose response options range from 0 (“never”) to 6
(“every day”) [64, 70, 81].
Data Analysis Does not require complex statistical tools to analyze [64, 70]. It
provides meaningful stratification of risk of high burnout in the domains of EE and
DEP, with results that show these two items correlate strongly with EE and DEP of
burnout as measured by the full MBI-HSS [80–82]. The results can serve well as
predictive factors comparative to the full MBI [80–82].
Limitations [64, 70] There is an associated cost with using this tool. There is no
construct validity in other healthcare professionals other than physicians and medi-
cal students. The instrument may not be sensitive to interventions to change burn-
out. These items are not meant to provide comprehensive assessment or monitoring
of burnout for individual respondents but instead can be used more as an initial
screening tool or “snapshot” in instances where it is too hard to administer the full
version of the MBI; the results can subsequently influence where further assessment
is needed [64, 70, 80, 82].
Benefits [64, 70] Brief assessment, therefore, reduces respondent burden, as it

takes less than 3 minutes to complete [81]. Therefore, it can be helpful for larger
surveys of healthcare professionals or institutions, as an initial screener. It is com-
paratively simple to analyze as it does not require sophisticated statistical resources.
It has strong construct validity in US physicians. Strong psychometric data show
that scores correlate with stakeholder outcomes of interest such as medical errors,
turnover, suicidal ideation, and poor professionalism [64, 70, 80, 82].
Oldenburg Burnout Inventory (OBI)
This tool is not specific to healthcare professionals and can measure burnout in any
vocational group. This is a measure released in 2002 developed by German research-
ers in response to the MBI not having negatively worded items [64, 70].
Format A 16-item self-administered questionnaire with positively and negatively

framed items. It covers two main domains of burnout: exhaustion and disengage-
ment from work. There are various questions for each domain, and answers are in
the form of a 4-point Likert scale from strongly agree [1] to strongly disagree [4].
Exhaustion is described as an enduring consequence of strong physical, affective,
and cognitive strain. Disengagement from work is described as negative attitudes
toward work objects, work content, or work in general [83].
Data Analysis Each burnout domain is treated distinctly as a continuous vari-

able [64].
Limitations [64, 70] No national benchmark data for US healthcare workers

(therefore currently cannot compare results against empirical national norms).
Existing data correlating instrument to variables of interests are limited to outside of
the United States such as studies of Swedish nurses [84–86], Chinese nurses [87],
and Dutch or German physicians [83, 88]. However, it is broadly applicable to any
occupation not just healthcare professionals; therefore the tool can be utilized for
those whose job is mainly about processing information or for those who perform
physical work and do not necessarily have direct patient contact, but in the context
of assessment of oncology providers, that is often not the case [64, 70, 83].
Furthermore, the instrument is lengthy as it is a 16-item-long tool and takes approx-
imately 10 minutes to complete. The results necessitate statistical resources and
expertise to analyze and therefore are moderately complex to evaluate. Lastly, it is
unknown if the tool is sensitive to meaningful effect sizes from interventions; there-
fore empirical evidence is lacking that supports if it sensitive to change [64, 70].
Benefits [64, 70] The tool is publicly available for free use. Translations of the
tool are available in multiple languages.
Copenhagen Burnout Inventory (CBI)
This tool was developed by researchers from Denmark and released in 2005.
Format This 19-item questionnaire measures burnout as defined by focusing on

physical and psychological fatigue and exhaustion within three different domains.
Six questions focus on the personally experienced domain, for example, questions
such as “How often do you feel tired?” or “How often do you feel worn out?”
Another six questions focus on the work-related domain, for instance, questions
such as “Do you feel that every working hour is tiring for you?” or “Do you feel
burned out because of your work?” The last six questions focus on the client-related
domain (or a similar term such as patient, resident, student, inmate, etc.), for
instance, questions such as “Do you find it hard to work with clients?” or “Does it
drain your energy to work with clients?” There are positively and negatively framed
questions, and answers vary on a scale of either “always, often, sometimes, seldom,
and never/almost never” or “to a very high degree, to a high degree, somewhat, to a
low degree, and to a very low degree” [89].
Data Analysis [64, 70] Each domain is independently analyzed as a continuous

variable. The answer selections are translated into scores of 0, 25, 50, 75, and 100.
Subsequently, items within the subscale are averaged, with one item reverse scored.
Greater scores signify a greater degree of burnout. Possible score range for all scales
is 0–100 [64, 70, 89].
Limitations [64, 70] It is 19 items long so it can contribute to respondent burden

as it will take between 10 and 15 minutes to complete. The results necessitate statis-
tical resources and expertise to analyze and therefore are moderately complex to
evaluate. Limited data show that scores connect with outcomes of interest among
healthcare professionals in the United States and have mostly occurred within stud-
ies from abroad with small sample sizes hence are not necessarily generalizable
studies [88–91]. There is no construct validity evidence in US physicians or other
healthcare professionals and a limited construct validity in non-US physicians and
other healthcare professionals. Lastly, it is unknown if the tool is sensitive to mean-
ingful effect sizes from interventions; therefore empirical evidence is lacking that
supports if it sensitive to change. It is broadly applicable to any occupation not just
healthcare professionals.
Benefits [64, 70] The measurement tool is free and publicly available. Translations
in several languages are available [64, 70].
Single-Item Burnout Measures
Some health systems and investigators use a single item for initial screening
purposes.
Format [64, 70] Single-item. The question and answer items can vary in different
publications. One common truncated version of the larger burnout measures is the
Physician Worklife Study (PWLS) single-item which asks “Overall, based on your
definition of burnout, how would you rate your level of burnout?” Answer: possi-
bilities range from the following – (1) “I enjoy my work, I have no symptoms of
burnout”; (2) “Occasionally I am under stress and I don’t always have as much
energy as I once did, but I don’t feel burned out”; (3) “I am definitely burning out
and have one or more symptoms of burnout, such as physical and emotional exhaus-
tion”; (4) “The symptoms of burnout that I am experiencing won’t go away. I think
about frustration at work a lot”; and (5) “I feel completely burned out and often
wonder if I can go on. I am at a point where I may need some changes or may need
to seek some sort of help” [64, 92]. However, another version of this question pulls
the question “I have become more callous toward people since I took this job” from
the MBI-HSS and instead looks more at DEP [41].
Data Analysis Frequently classified as either not having burnout if a respondent

answers 1 or 2 or having elements of burnout if a respondent answers 3 or above,
although such classifications are not empirically tested for validity within the litera-
ture. The PWLS is mostly correlated to EE and not the other domains, whereas the
second example of a single-item question listed above correlates instead to the
depersonalization subscale [41, 80, 93, 94].
Limitations [64, 70] May oversimplify the analysis as it focuses on only single
constructs of the multifaceted concept of burnout, therefore may miss people who
manifest burnout in different ways [70]. No national benchmark data, and only lim-
ited data, showing that results correlate with outcomes of interest to stakeholders
[95, 96]. Limited construct validity evidence in US physicians (studies with small
sample sizes, and almost singularly studying primary care providers, thus having
limited generalizability). No construct validity evidence in other healthcare profes-
sionals. Too brief of a tool to have strong psychometrics associated with it in the
empirical literature. Not specific to healthcare professionals and therefore can be
used in any occupation.
Benefits [64, 70] Limits both organizational and respondent burden, as it is the
shortest of the measures and easiest to administer and analyze the results. Publicly
available and free for use.
The Physician Well-Being Index (WBI)
US researchers from Mayo Clinic created the seven-item measure which was
released in 2010 and then expanded to a nine-item measure in 2014.
Format [64, 70] Measures six dimensions of distress and well-being including
burnout, depression, stress, fatigue, and mental and physical quality of life. The tool
is a seven- to nine-question survey with yes or no response choices. The nine-item
expanded version also evaluates work-life balance and meaning associated
with work.
Data Analysis [64, 70] Respondents are probed to answer seven yes/no questions
and receive a summative score from 0 to 7 (1 point for each item answered “yes”),
based on the answers. Therefore, lower scores are more favorable. For the seven-
item version, a threshold score to identify individuals in high distress is ≥4 for
medical students and practicing physicians, ≥5 for residents, and ≥2 for other US
workers including advance practice providers. In the expanded nine-item version,
the original seven items are scored in the established manner, with responses to
meaning in work and satisfaction with work-life balance items resulting in 1 point
being added or subtracted, which resulted in a score range of −2 to 9. In a sample of
medical students, physicians, and US workers, every 1 point increase in score
resulted in a stepwise greater likelihood of distress and risk for adverse personal and
professional outcomes.
Limitations [64, 70] There is an associated fee for using the organizational inter-
active online version of the measurement tool. It is unknown if measure is sensitive
to change.
Benefits [64, 70] Multiple dimensions, short seven to nine items, so low respon-
dent burden associated with the measure as it takes approximately 5 minutes to
complete. Free for individual research use or nonprofit public use. Relatively simple
to analyze as it does not necessitate complex statistical tools to understand the
results. There is a context to analyze results within, as there is national benchmark
comparative data accessible for the screening tool empirically tested on residents,
fellows, physicians, medical students, advanced practice providers, and the general
population [64, 97]. Moderately strong data show that scores correlate with out-
comes of interest to stakeholders among US healthcare professionals such as clini-
cians’ health, intent to leave, and the quality and care delivered to patients [97–104].
Broadly applicable to any profession. Moderately strong construct validity evi-
denced in US physicians and other healthcare professionals.
No Diagnostic Criteria for Burnout
Burnout is not recognized as a distinct diagnosis in the current DSM (Diagnostic

Statistical Manual of Mental Disorders) [105]. There is no agreement on the defini-
tion of burnout and its core symptoms [106]. There are also significant associations
between certain personality traits, and workplace characteristics may be predictive
factors for burnout [107] that can make categorization into a DSM entity confusing
and potentially misleading.
Its clinical characteristics are often subsumed under other diagnostic entities
such as adjustment disorders, major depression, chronic fatigue, stress-related dis-
orders, or substance use disorders, highlighting the focus on the individual’s liabil-
ity for suboptimal coping. Although a unique DSM diagnosis would not alleviate
this emphasis on the individual, the lack of recognition of this as a clinical entity
may hinder serious study of solutions to this complex problem and potential medi-
cal compensation.
Summary
Continuing efforts to refine proper burnout assessment in healthcare professionals

persists. It is important to look at the variety of benefits and limitations to each of
the available tools before selecting a tool for assessment. Although substitute con-
densed MBI assessments have been proposed, and entirely separate tools have been
developed independent of the MBI structure, the MBI remains the current “gold
standard” for the assessment of healthcare staff [52]. Therefore, when screening and
assessing oncology healthcare professionals, the full MBI represents the preferred
version of assessment. However, the shortened two-item MBI-HSS or the WBI rep-
resents alternative legitimate option for the assessment of oncology healthcare staff
if the full MBI is not pragmatic based on institutional confines.
Basic Assessment Screening Suggestions Going Forward
The complexity of measuring burnout accurately in oncology providers may be vital

to preserve the well-being of patients and the sustainable development and preser-
vation of expert providers. Marked variation in burnout definitions, assessment
methods, and study quality has been noted [108], leading to difficulty assessing
accurate prevalence rates. The development of a consensus definition of burnout and
of standard measurement tools to assess the effects of ongoing distress on health-
care givers, and oncology providers in particular, is vital to more fully clarify indi-
vidual subjective complaints or symptoms, within a coherent and addressable
syndrome. Instruments, like the MBI, need to be general to capture nuances that
cross oncology specialties but specific enough to identify unique job and environ-
ment influences. They must be elaborate enough to pick up meaningful details but
short enough to be successfully completed by busy, often tired clinicians. Successful
instruments should have validity over time with the ability to be utilized repeatedly
over time and look at not only individual characteristics and consequences of burn-
out but also the systemic and resource variables that contribute to this syndrome that
needs to be addressed on a macrocosmic scale.
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The Ethical Implications of Burnout:
A Moral Imperative to Prioritize 7
Physician Well-Being, Resilience,
and Professional Fulfillment
Fay J. Hlubocky, Mehmet E. Dokucu, and Anthony L. Back
Case Presentation
Dr. A has always been an energetic, dedicated medical oncologist and a successful
clinical trials investigator. Now, at age 45, he is fatigued, cynical, and lonely. Dr. A’s
anger is directed at the healthcare system for the perceived coercion to see more and
more patients per week in less time. His frustrations surround the limited clinical
time he can spend with patients with advanced cancer who require and desire
detailed information pertaining to disease, prognosis, and treatment. As a result, Dr.
A also experiences irritability coupled with a sense of guilt in the care of these
patients for what he views to be increasingly demanding, yet expected, tempera-
ments and needs due to their role as patients with advanced cancer. The joy of
oncology practice that he relished is only a memory. He detests the hours devoted to
the electronic medical record and clerical administration which he believes contrib-
utes to his loss of identity and autonomy and has violated his values as healer, as an
oncologist. Although Dr. A’s relationships with patients once thrived, they no longer
provide the same level of satisfaction. In fact, even his treasured discussions with
F. J. Hlubocky (*)
The University of Chicago Medicine, Department of Medicine, Section of Hematology/
Oncology, Maclean Center for Clinical Medical Ethics, Program for Supportive Oncology,
Chicago, IL, USA
M. E. Dokucu
Northwestern University Feinberg School of Medicine, Department of Psychiatry and
Behavioral Sciences, Chicago, IL, USA
A. L. Back
Division of Oncology, University of Washington, Fred Hutchinson Cancer Research Center,
Seattle Cancer Care Alliance, Seattle, WA, USA

88 F. J. Hlubocky et al.
his wife, who has been a supportive partner, has not relieved these feelings of intense
isolation and pessimism. As he meets with colleagues, Dr. A reports feeling cynical
regarding his future career and presents the following question to them: “Is any of
this worth it?”
Introduction
The role of the physician is a rewarding experience, yet, the complexity of care
provided to seriously ill, frail, vulnerable patients in an ever-evolving healthcare
environment places significant demands on the individual clinician and workforce.
It is the clinical ethics framework of care – patient autonomy, respect for patient
welfare, avoidance of harm, the provision of justice – which serves as a model for
action in the delivery of optimal medical care and further solidifies the moral duty
of the physician to the patient. Yet, mounting clinical care responsibilities, coupled
with increasing administrative demands on clinical time, productivity, and the
evolving medical landscape, both directly and indirectly compromise the physi-
cian’s moral obligation to the patient. This places the dutiful physician, such as Dr.
A, at significant risk for occupational stress in the form of the burnout syndrome.
Burnout arises, intensifying when physicians realize their ethical standards and val-
ues are not shared by their organization. Hence, burnout is a direct consequence of
a violated, diminished personal and professional values process. Moreover, as Dr. A
finds it increasingly difficult to repeatedly translate his moral decisions to ethical
action, moral distress develops. When physicians experience burnout and moral dis-
tress, the physician-patient relationship is in significant jeopardy. Thus, from an
ethical perspective, enhancing oncologist well-being is vital to initiating and main-
taining the physician-patient relationship in medicine. Here, the authors, experts in
clinical psychology, psychiatry, medical oncology, clinical ethics, and burnout, will
present a theoretical understanding of burnout with associated risk factors and con-
sequences with a central focus on the seminal ethical implications of burnout on
physician well-being and resilience with proposal for intervention using the medical
oncologist as an example. However, despite this focus, it is important to note that
these ethical implications are applicable for all physicians despite designated
specialty.
The Burnout Syndrome
Burnout was first identified in the mid-1970s by psychologist Dr. Herbert

Freudenberger [1, 2] as a syndrome arising as occupational stressors coupled with
additional life pressures exceed the ability to thrive resulting in physical and mental
distress [1–11]. In the United States, burnout has been found to be highly prevalent
in the physician workforce and is estimated to affect 50–55% of physicians at some
timepoint during their careers [7]. Burnout has been empirically defined as an
occupational-related syndrome characterized by signs of physical and emotional
7 The Ethical Implications of Burnout: A Moral Imperative to Prioritize Physician… 89
Table 7.1 Signs and symptoms Physical and emotional exhaustion

of burnout Chronic fatigue
Cardiovascular issues
Cognitive dysfunction
Insomnia
Gastrointestinal complaints
Affective and behavioral distress: anger,
irritability, depression, anxiety
Cynicism and depersonalization
Pessimism
Isolation
Demoralization
Detachment
Low sense of personal accomplishment
Feelings of inefficacy
Decreased productivity
Overall dissatisfaction in work-life balance
exhaustion, cynicism and depersonalization (sense of detachment or disengage-

ment), and a low sense of professional accomplishment [1–11]. These three-dimen-
sional burnout domains exist along a continuum distinguished by distinct unique
symptoms and an overlap of symptomatology (Table 7.1) [1–3]. For example, the
symptoms of physical and emotional exhaustion include chronic fatigue, cardiovas-
cular issues, cognitive dysfunction, insomnia, gastrointestinal complaints, and
affective and behavioral distress (anger, depression, anxiety). Cynicism and deper-
sonalization are characterized by signs of pessimism/depression, isolation, demor-
alization, and detachment. A low sense of personal accomplishment leads to a sense
of inefficacy, decreased productivity, and overall dissatisfaction in work-life bal-
ance. The initial physical and emotional symptoms of burnout slowly develop over
the course of 1 year [1–3]. Burnout is a physical and mental response that manifests
as chronic occupational and interpersonal stressors arise and persevere over an
extended period of time [1–17]. Dr. A expresses a pessimistic attitude toward his
role due to mounting cumulative institutional demands as an oncologist resulting in
overall decreased productivity and increased workload clinically and administra-
tively. Increasingly, these signs and symptoms adversely impact Dr. A’s well-being
leading to adverse long-term personal and professional consequences (Table 7.1).
Risk Factors Associated with Burnout
Multiple individual and organizational risk factors are associated with an increased
susceptibility to develop burnout in medicine [2, 5–28]. Individual risk factors are
internally based dispositional factors consisting of sociodemographic and personal-
ity characteristics. Prior empirical research has identified specific individual burn-
out risk factors including female gender, younger age (≤55 years), junior physicians
(residents, fellows, physicians ≤5 years from training), years in practice, and single,
unmarried/non-partnered physicians [4–17, 21–28]. Personality characteristics rec-
ognized as independent burnout risk factors include compulsivity, neuroticism,
extraversion, conscientiousness, alexithymia, psychological hardiness, and Type A
behavior [2, 21–28]. Lastly, external, environmental, occupational, and organiza-
tional risk factors identified as contributors to burnout include increased direct
patient care time; high occupational demands; lack of autonomy over daily tasks;
increased administrative responsibilities; use of electronic medical record (EMR)
systems; telehealth; limited ethical, moral decision-making compromising physi-
cian values; ambiguous job expectations; lack of social support; and the evolving
healthcare landscape [6, 9, 21–28]. As a mid-career, conscientious, physician who
lacks autonomy and is incapable to meet his moral expectations as he works exceed-
ingly long hours in direct patient care with secondary expectations to be a clinical
investigator, Dr. A is at an increased risk of experiencing significant consequences.
Personal and Professional Consequences of Burnout
Burnout is not a formal medical or mental health disorder as it has been primarily
recognized as an occupational-related condition by the World Health Organization
[29]. It is presently incorporated in the ICD-11 with a recently expanded, compre-
hensive definition under the category “Problems related to employment or unem-
ployment” (QD85 Burnout) resulting from chronic workplace stress which has
adversely impacted the individual’s overall health [2, 29]. Psychiatric disorders,
depression and post-traumatic stress disorders, have been identified both as precur-
sors to the development of burnout and consequences [2, 6–14, 17, 21–28, 30–32].
Burnout has been compared to both stress and depression given similar shared
symptomology and metabolic, physiological systems involved (e.g., systematic
inflammation or autonomous nervous system) [30–35]. However, unlike stress,
which tends to be fairly short term and resolves completely once the stressful situa-
tion has changed, burnout is a complex, insidious process progressively developing
over an extended period of time [2, 3]. The burnout process occurs in 12 dynamic
stages ranging from a compulsion to prove self to a development of multiple behav-
ioral mood changes, causing and resulting in the final burnout syndrome [2, 3, 32].
It is due in part to this gradual development in exhaustion symptoms that burnout is
challenging to detect, identify, and intervene early on, therefore resulting in long-
term enduring health consequences for the individual [2, 6–14, 17, 21–28, 30–35].
Unlike stress and depression, burnout symptoms may resolve once the individual
changes a job, or if the work environment is altered. Yet, long-term unaddressed
burnout leads to personal consequences such as chronic health conditions (heart
disease, stroke, obesity) or mental health conditions (depression, anxiety, substance
use, and suicide [2, 6–14, 17, 21–28, 30–35]. Professionally, long-term burnout may
lead to diminished quality care and reduced professional satisfaction and accom-
plishment [21, 22]. To date, self-reported screening measurement scales such as the
Maslach Burnout Inventory (MBI) [36] and the Mayo Clinic Physician Well-Being
Index [37] have been utilized in occupational, clinical, and empirical settings to
assess burnout and burnout-related signs for various health and medical staff popu-
lations including in oncology. Yet, in addition to the abovementioned measures, the
identification of specific work-life areas and occupational factors that contribute to
burnout is critical in order to evaluate long-term practice health and organizational
processes on physician well-being.
Work-Life Dimensions Associated with Burnout
Occupational well-being is conditional on the perceived confluence between the

individual’s unique capabilities and workplace factors within the environment.
Leiter and Maslach empirically identified the specific occupational factors predic-
tive of employee burnout [38]. A fit between each dimension and the environment
increases employee engagement. Six dimensions of work-life were found to be con-
sidered most relevant to support a model of the organizational context of burnout for
the development of a relationship between the individual, employee, and their work
[38]. These identified dimensions include the following: workload, control, reward,
community, fairness, and values (Table 7.2).
A brief descriptive summary of each work dimension can be applied in the analy-
sis of the relationship between the employee and work, especially physicians, such
as the oncologist, and the clinical environment [38, 39]. The dimension of workload
is significant for an understanding and evaluation of the development of burnout in
the physician. If the overall occupational demand of balancing clinical care with
administrative responsibility transcends human ability, emotional exhaustion arises
[39]. In fact, increased workload has been associated with high emotional exhaus-
tion in the physician [39]. Control encompasses the perceived capacity of the physi-
cian to influence occupational-related decisions, to utilize personal autonomy and
independence, and to gain access to internal institutional resources (e.g., social sup-
port, reward) in order to conduct and complete work tasks [39]. That is, control
safeguards the physician from increased work demands. It shares a close, predictive
relationship to the companion dimensions of workload, reward, fairness, and com-
munity [39]. The dimension of reward is evaluated within the effort-reward-
imbalance framework centering on how reinforcement influences physician
behavior and reveals to what degree intrinsic and social rewards remain consistent
with the physician’s expectation [39, 40]. If physicians hold the perception of aban-
donment due to an imbalance in the institutional reward system, they will feel
Table 7.2 Dimensions of the work environment Workload

Control
Reward
Community
Fairness
Values
disconnected from the values or mission of the organization [39, 40]. Community is
the specific work-life dimension involving the evaluation of the quality of social
interactions (e.g., peers, patients, oncology team members, organizational leaders)
oncologists experience within the clinical environment. Brom and colleagues report
that empirical research devoted to social influences and the dimension of commu-
nity focus on issues of peer support, interpersonal dynamics, cohesiveness, comrad-
ery, and teamwork [39]. The fairness dimension depicts the degree to which
decision-making within the clinical environment is viewed as equitable, just, and
reasonable [39]. Lastly, the values dimension highlights the morals, principles, ethi-
cal standards, and motivation that draw the physician to medicine or the oncologist
to the occupational field. In the values dimension, if incongruence exists between
physicians and the clinical work environment, physician engagement becomes chal-
lenged, resulting in unfavorable actions [39]. Agreement between physician-work
values is critical to oncologist engagement. If the physician views a fit between all
other dimensions, it is personal and professional values are respected [39, 40]. Yet,
if the physician perceives a weak fit between dimensions, work-life functions as a
stressor, thereby threatening overall well-being.
Using Leiter and Maslach’s model, any mismatch, incongruence, between the
oncologist and the clinical work environment in these six dimensions diminishes the
capacity for energy, involvement, and efficacy [4, 41]. To assess the fit between the
employee-work environment and the overall occupational working condition of the
employee, including the physician, the Areas of Worklife Survey (AWS) has been
developed and utilized [38]. The AWS is a well-validated, widely accepted brief
questionnaire used across multiple organizational environments, including medi-
cine, to evaluate these six critical dimensions in order to determine the respondent’s
perceptions of workplace qualities that directly contribute to the employee’s experi-
ence of work engagement or burnout [38]. The AWS can be coupled with the MBI
as a comprehensive work-life assessment for burnout prevention, mitigation, and
remediation for many employees including physicians, especially in oncology
[36, 38].
Prevalence in Oncology
The global incidence of burnout has dramatically increased over the past decade for
oncologists in the United States, Europe, and Australia [42–46]. In 2005, Allegra
and colleagues’ survey study of over 1700 oncologists was the first to reveal that
nearly 62% of oncologists in community practice in the United States reported
experiencing symptoms associated with burnout including the top three signs: frus-
tration (78%), emotional exhaustion (69%), and lack of work satisfaction (50%)
[42]. Today, in the most comprehensive study of oncologist burnout to date, 45% of
US American Society of Clinical Oncology (ASCO) member medical oncologists
have reported experiencing emotional exhaustion and/or depersonalization symp-
toms related to burnout [43]. In Europe and Australia, burnout rates vary signifi-
cantly ranging from 52% to 78% depending on medical oncology specialty, practice,
healthcare systems, and screening tools utilized [7, 42–46]. For example, in a mul-
tinational study centering on the oncologist experience of the burnout syndrome in
Eastern Europe, 72% of oncologists were found to be at high risk for burnout with
45% at high risk for MBI exhaustion, 28.7% for depersonalization, and 47.3% for
personal accomplishment [44]. A mailed survey study conducted in France involv-
ing 340 medical and radiation oncology fellows using the MBI revealed that 44%
believed burnout was prevalent and associated with low perception of health status
and a desire to leave medicine [45]. In Australia, 36% of surveyed gynecological
oncologists reported a high degree of emotional exhaustion, with 43% reporting a
desire to leave current position, 29% considered retirement, and 57% wished for
reduced work hours [46]. This research captures only a few of multiple significant
studies uncovering the global scale of the prevalence of burnout in medical oncol-
ogy in uniquely different oncology and healthcare systems. A continuation of the
investigation of the incidence and development of burnout is needed for additional
identification of risk factors, including ethical dilemmas within practice that arise,
further intensifying oncologist distress, and hinder immediate intervention.
thical Dilemmas Associated with Burnout in Oncology:

E
Moral Distress
Burnout is at the center of a group of related concepts and subtypes (e.g., compas-
sion fatigue, empathy fatigue) with intersecting features, yet it shares a unique rela-
tionship with a form of moral strain and suffering experienced within the dynamics
of the occupational, clinical environment, known as moral distress [18–20, 47]. This
moral distress arises as a direct consequence of both the ethical dilemmas and fail-
ure to practice according to the physician’s personal and professional values, mainly
due to a perceived lack of professional support from organizational and social con-
straints [48–50]. It transpires as the physician’s moral, ethical framework directly
conflicts with values of the healthcare, oncology system [51, 52]. According to
Rushton, moral distress adversely impacts the clinician’s mind, body, or relation-
ships in response to a clinical circumstance where the clinician is cognizant of the
moral problem, recognizes moral responsibility, and formulates a moral decision on
what corrective action should be undertaken [19, 53, 54]. However, given the real,
genuine presently occurring or perceived constraints within the clinical environ-
ment, the clinician participates in perceived moral transgression. For physicians,
especially in oncology, life and death decision-making and perceptions that treat-
ment is futile have been identified as common ethical challenges predictive of moral
distress [48, 55–57]. More specifically, recent empirical evidence reveals that
oncologists are particularly at high risk for developing moral distress due to their
role in the delivery of serious news, perceptions regarding futility of treatment, and
end-of-life decision-making [56–58]. It has also been found that moral distress will
linger and endure in oncologists for the long term if coupled with emotional distress
[58]. Morally distressing situations result from the collective experience of repeated
events rather than an individual scenario. As moral distress remains unresolved,
including its associated ethical turmoil, moral residue emerges as a result of the
unaddressed psychological struggle, and thereby acceptance of future events
become less likely [51]. As this moral residue builds, moral injury arises and inten-
sifies with subsequent distress. Moral injury, a related concept, well-described in the
context of military trauma, results from actions (or lack of action) which violate the
individual’s moral, ethical code [58]. It is not a mental health condition, yet it causes
similar detrimental consequences to burnout and poor mental health. Moral injury
develops when a clinician’s ability to provide optimal patient care routinely con-
flicts with, or is repeatedly frustrated by, other factors. It has been suggested that
moral injury destroys the physician’s ethical framework due to either a single event
of violation or repeated events of moral distress [51]. For oncologists, although no
empirical evidence exists to date that moral injury is prevalent in oncology, as a
concept, it has been widely accepted given it resonates with the oncologist anec-
dotal experience that burnout is a systems issue driven by work characteristics [51].
Consequently, given the impact of moral strain on oncologist well-being, organiza-
tions have a responsibility to support oncologists in living authentically to their
intrinsic core values by respecting physician values and fostering ethical climates to
support and sustain the oncologist.
thical Implications of Burnout in Oncology: The Role

E
of the Physician’s Personal and Professional Values
If burnout remains unaddressed, it has the potential to harm the physician-patient

relationship [48–50]. For many physicians who experience incongruence between
their values and their organizational values, the only available solutions to address-
ing burnout involve changing employment, early retirement, or a departure from
medicine. In addition to the underlying, well-accepted ethical standards and core
principles of beneficence, nonmaleficence, justice, and respect for patient auton-
omy, additional fundamental, deeply sustained personal and professional values are
also adversely impacted by the burnout syndrome. It is the values process impeded
by hindered ideals and goals that transforms exhaustion into burnout [41]. Burnout
undermines the physician’s primary core values, a sense of purpose, identity, integ-
rity, virtue, altruism, and autonomy (Table 7.3) [41, 58–61].
Most importantly, burnout is a direct violation of physician autonomy and the
personal and professional values which influence clinical decision-making for
patient care [62]. Adequate ethical judgment for patient care requires an apprecia-
tion of how guiding ethical principles should be appraised by the oncologist.
Physicians must be able to discern moral questions in practice; make reliable, ethi-
cal judgments; and gain awareness of conflict between personal and ethical judg-
ments. Yet, burnout can directly impede and adversely impact the physician’s
capacity to make informed recommendations regarding optimal treatment options
and overall patient care [63–65]. As well, indirectly this decision-making is related
to the fairness dimension of workload which represents the degree to which deci-
sions within the clinical work environment are viewed as equitable. Therefore, the
Table 7.3 Burnout challenges, physician Sense of purpose and meaning

values Identity
Integrity
Virtue
Altruism
Autonomy
only viable solution to addressing burnout involves not only respect for physician
values, however, but also an alignment of shared, mutual guiding normative values
between oncologist and the organizational mission that can sustain not only indi-
vidual well-being but also practice health and in the long term the overall workforce
[60]. Yet, this can only be accomplished if the organization fosters a culture of heal-
ing through the identification and recognition of the fundamental, essential values
of the physician [66].
In a novel critical review, Moyo and colleagues identified a comprehensive set of
personal and professional values in order to create an aspirational model for physi-
cians and other clinicians across disciplines [62]. After a rigorous review, the authors
created a framework for clinician values which were directly matched with values
from the well-accepted Schwartz models (as defined within each parenthesis per
authors) and included the following values: authority (power); capability (achieve-
ment); pleasure (hedonism); intellectual stimulation (stimulation); critical thinking
(self-direction); equality (universalism); altruism (benevolence); morality (tradi-
tion); professionalism (conformity); safety (security); and spirituality (spirituality)
[62]. The foremost values identified as guiding principles for the provision of care
for clinicians include altruism, equality, and capability [62]. Although this values-
centered framework was constructed to aid clinician decision-making for patient
care, it can also serve as an institutional guide to inform organizational recognition
of the essential physician values required for staff support. As well, this framework
will illuminate physicians’ own self-understanding and awareness of the relevant
ideals that play a role in their own clinical decision-making for care.
Although the values of physicians should naturally align with the values of the
organization, conflict occurs if both entities differ in their goals regarding the provi-
sion of patient care. According to Gabel, medicine should underscore the impor-
tance of moral clinical practice and underlying physician values in order to promote
benevolent patient-centered care [67]. The healthcare system, and specifically the
organization, has a moral, ethical obligation and duty to facilitate collaborations
with their physician employees to meet this shared goal. Many physicians, includ-
ing the oncologist, experience burnout when they hold the belief that their values
such as those noted above are not only shared by their organizations but also com-
promised. This threat to personal and professional values arises when physicians
perceive they themselves are hindered from providing optimal clinical care they
desire to provide based upon training and expertise [67]. Physicians whose values
are endangered also hold the perception that overwhelming work demands intimi-
date their own values. They become motivated to respond to this overall stress by
defending their resources, their overall belief system. These appraisals are com-
monly held by those who share the same culture, such as medicine. This process,
known as the Conservation of Resources theory, provides a framework of under-
standing physician stress as these very resources are predictive of work-related
health outcomes including burnout [39, 67–70]. In oncology, for example, the pro-
fessional responsibility of the oncologist involves providing high-quality cancer
care based upon the following factors: clinical expertise, ethical values, the indi-
vidual patient situation, and the oncologist-patient relationship with an enhanced
understanding of patient preferences for treatment and/or end-of-life care [71, 72].
It is vital for the organization to empower the physician to address existing incon-
gruence between these values and the organizational values.
Empirical research has been conducted to investigate this relationship between
the impact of existing incongruence between physician values and organizational
values. Overwhelmingly, study has confirmed that value congruency is critical to
employee, specifically physician, engagement and burnout [3, 38, 39, 73]. In fact,
both workload and value congruence have been identified as unique, individual,
contributing factors relevant to physician burnout. Leiter and colleagues conducted
an important physician survey study that supports this evidence [73]. Here, physi-
cians were surveyed to identify the relationship between workload and value con-
gruence for a random sample cohort of physicians in Canada using a version of the
MBI-General Survey and AWS [36, 38, 73]. The results obtained indicated that
physician participants experienced moderate burnout scoring positive exhaustion,
average cynicism, and mildly negative professional efficacy [73]. Additional mul-
tiple regression analyses revealed workload and values congruence predicted
exhaustion and cynicism for both male and female physician participants [73].
Values congruence also predicted physician professional efficacy for both genders
[73]. In summary, these research data confirm that physician conflicted professional
values are predictive contributors to exhaustion, cynicism, and low professional
efficacy [73]. As well, increased workload plays a contributing, predictive role for
exhaustion and cynicism. Finally, the congruence of individual values with health-
care system values was of greater significance for female over male physicians [73].
The study performed here and corresponding quantitative data provide evidence to
help provide a pathway for the development of organizational strategies designed to
uphold fairness, respect physician values, and foster resilience as a means to pro-
mote overall physician well-being.
Cultivating Resilience
Resilience is a multifaceted psychological phenomenon which emphasizes the

human capacity to cope with, overcome, and become strengthened by adversity
[74–82]. Current clinical and research efforts center on the strengths of the indi-
vidual, rather than the individual’s vulnerability, as a means of empowerment to rise
above adversity, and persevere, resulting in positive adaptation (Table 7.4). To date,
the theory and study of resilience have shifted from a focus on the long-term adverse
Table 7.4 Three components of resilience Strength of the individual

Rise above adversity
Positive adaptation
consequences of trauma to a focus on strength, triumph, and competence to build

interventions tailored to foster resilience [74–82]. The concept of resilience flour-
ished within the developmental psychology field through the study of children who
were able to thrive, survive, and overcome negative abusive childhood environments
with poor parenting [76–78]. Resilience has also been applied to survivors’ popula-
tions of war, trauma and the military [82].
esilience: Supports Health and Enhances Coping Through

R
a Psychobiological Mechanism
At present, empirical research has enhanced the scientific community’s understand-

ing of the concept of resilience by placing an emphasis on specific, unique factors
that support human health and enhance coping rather than highlighting stress-
related factors associated with disease or trauma [75, 76, 81]. Although evidence
indicates that environmental, neurologic, social, and cultural factors are associated
with the development of resilience, from a psychobiological perspective, resilience
is believed to be a physiological positive adaptation to stress as it is associated with
maintenance of the following systems: somatic, autonomic (sympathetic and para-
sympathetic), and central nervous. The specific brain regions associated with resil-
ience involve the prefrontal cortical region and amygdala [83–85]. Additionally,
decreases in the stress hormone cortisol, neuropeptide Y (an anxiety neurotransmit-
ter), and 5-dehydroepiandrosterone prevent initiation of the stress response by
decreasing sympathetic nervous system activation [83–85]. Also, elevated levels of
the neurotransmitters, serotonin and dopamine (“the reward center”) and neuropep-
tide oxytocin, have also been linked to resilience [83–85]. Positive emotions (e.g.,
happiness; optimism) play a crucial role in the development of resilience. Although
it may appear that certain individuals are genetically predisposed to effectively cope
with stressful situations, resilience is not necessarily an inherited trait but rather a
skill that can be learned and mastered. Yet, despite this strong scientific evidence,
questions surround how to adequately describe and define resilience due to its
complexity.
How Is Resilience Defined?
To date, a universally accepted definition of resilience does not exist given its com-
plex nature encompassing social, psychological, biologic, and cultural factors that
act together to determine how the individual responds to stress [78, 79, 81]. The
definitions of resilience continue to advance and grow. However, most definitions
and researchers agree that for resilience to be demonstrated, both adversity and
positive adaptation must be present [78–82]. Resilience is a positive response to
adversities in the form of everyday minor stressors to key life-altering events.
Resilience has been described as both a trait and a process, either present or absent,
inherited or learned; however, according to Southwick, a well-known resilience
expert, and colleagues, it likely exists on a continuum ever present to differing
dimensions across several life domains influenced by psychological characteristics
within the stress process [76, 78–81]. Ideally, resilient individuals persevere in the
face of adversity and life stress leading to transformative positive growth, accep-
tance, and a sense of greater meaning in life. Yet, as a result of interaction with the
environment, resilience may change depending on the individual’s response to
stress and interactions with others within the environment [78, 79, 81]. For example,
a physician who is unable to positively adapt to work stress may successfully adapt
to his personal life, or the oncologist may have fostered resilience over the course of
time, during the late phase of career, yet not an early another phase such as in early
residency [77].
The Interplay Between Burnout and Resilience
Although several protective factors shield the individual against the development of
burnout, such as peer support, communication skills training, and self-care, resil-
ience is the key protective factor against burnout, as it shapes and enhances the
individual’s efficacy, engagement, and personal accomplishment [2–4]. Christine
Maslach, who has studied burnout extensively, believes that burnout involves not
simply the interaction between the individual and organization but also the indi-
vidual’s attitudes, self-appraisal, and appraisal of others [2–4]. As such, burnout can
be viewed as a barometer that measures a potentially toxic environment which does
not support the clinician to manage his needs and emotions. Moreover, Maslach and
colleagues found that consideration of the individual’s emotions promotes the indi-
vidual’s sense of control, commitment, and self-efficacy that further protects the
individual from burnout [2–4, 38, 41]. In addition, several key emotional personal-
ity variables associated with resilience significantly minimize the potential vulner-
ability to developing burnout, including a sense of coherence, thrivingness, hardiness
(commitment, control), optimism, emotional competence, learned resourcefulness,
self-efficacy, locus of control, potency, stamina, and personal causation [2–4]. The
individual’s ability to sustain and activate these resources in response to stress leads
to a transformative active coping style required to directly address stressors and
adversity. Research on physician resilience supports Maslach’s hypothesis. Zwack
and Schweitzer conducted an interview study of 200 physicians in Germany to iden-
tify health-promotion strategies used by senior physicians to maintain resilience
[86]. Three core thematic domains were identified to illustrate strategies and atti-
tudes used to activate resources that lead to active coping and the promotion of
resilience, including job-related fulfillment; behavioral practice (e.g., leisure activi-
ties, limited work hours, and professional development activities); and change in
attitudes (e.g., acceptance and attention to positive work endeavors). A recent study
identified that resilience was higher in physicians compared to the general popula-
tion, yet burnout rates were revealed to be significantly elevated even for those
physicians identified as highly resilient [87]. In short, despite stressful work condi-
tions, physicians, including oncologists, are able to activate resources to engage in
positive coping strategies needed to foster resilience, including resilience required
to address ethical challenges encountered in oncology care [88].
The Ethics of Resilience
The positive psychology phenomenon of resilience has been utilized to address

ethical issues, including those associated with burnout [89]. This application
modifies the liberal constructive rationalist framing centering on individual auton-
omy and provides a comprehensive, enhanced interpretation of the societal
responsibility for universally experienced ethical issues [88]. Here, the individual
is not viewed as a singular player in ethical dilemmas but an entrenched citizen of
society. Therefore, any moral assessment of the individual’s decisions and actions
involves communication and interaction between individual and society [89].
Moral resilience and the virtue of resilience are two such examples of the ethics
of resilience [89–96].
Moral Resilience
Moral resilience has been widely presented to date within the nursing literature and
applied to all clinicians in order to foster meaning from moral distressing patient
situations occurring within clinical practice. This form of resilience has been identi-
fied as a means to transform ethical dilemmas and the subsequent moral suffering
produced into action and growth beyond proposed individual and system-level
interventional approaches. Moral resilience involves the clinician’s ability and com-
petency to “sustain, restore or deepen integrity” in response to moral challenges,
uncertainty, suffering, or impediments [89–93]. It requires the capability of the cli-
nician to discern the appropriate levels of moral responsibility in an ethically com-
plex, conflict-laden clinical situations involving internal and external factors
associated with care [89–93]. Additionally, moral resilience necessitates the foster-
ing self-awareness, self-knowledge, and self-compassion with and a commitment to
values [89–93]. Self-confidence is essential to directly address immediate adversity
encountered in the clinical environment and adaptation to a continually evolving
healthcare landscape. Moral resilience is cultivated from a self-regulated, calm atti-
tude, strong values, and moral action [88–92]. It is a key element of clinician well-
being, empowering clinicians to positively adjust to adversity encountered daily
within the medical community and within the clinical environment. Although
research centering on the moral resilience experience for physicians remains lim-
ited, thematic identification from a recent qualitative study exploring
interprofessionals’ definitions of moral resilience revealed integrity and buoyancy

were required to address moral challenges experienced within the work of health-
care [94].
The Virtue of Resilience
Virtue ethics is the study of the individual’s moral, positive virtues or character
strengths that are fundamental for a good life [95–97]. This form of normative eth-
ics postulates that it is the practice of these very virtues that aids the individual in
the navigation of ethical challenges encountered in society. In the case of adversity,
the individual need not to shy away from suffering but merely connect to it, learn,
grow from it, thrive. This premise can readily be applied to the case of the physician
facing ethical dilemmas in the care of patients. For example, according to ethicist
David Hume, of the many moral virtues previously presented (e.g., courage, truth-
fulness, temperance, liberality, magnificence, proper ambition, righteous indigna-
tion, modesty, friendliness, wittiness, magnanimity), Hume believed that
perseverance and resilience are equally morally significant to life [95, 96]. This
practical ethical argument can be justified by Hume’s application and examination
of the following unique personal character strengths which include those “agreeable
to self”; “useful for self”; “agreeable to others”; and “useful to others” [95, 96].
Therefore, as resilience is recognized as a beneficial, favorable character strength
for the individual, resilience, in itself, is a virtue [96]. A virtue, such as resilience,
once acquired, becomes characteristic of the individual. Furthermore, this character-
based approach centers on how virtue, and specifically resilience, is acquired
through exposure, learning, and practice. Consequently, the individual’s ethical
code is shaped and formed by moral character.
Individuals develop this moral character through the practice of honesty, forti-
tude, and fairness in the presence of community where they ultimately thrive [95–
97]. Ultimately, this resilience benefits the culture and community the individual
shares in for the long term [95, 96].
This rationale has been supported in several published peer-reviewed empirical
research studies. The first study investigated the role of character strengths and vir-
tues for over 1000 youths who have been exposed to war and conflict in the Middle
East revealing character strengths moderated relationships between conflict expo-
sure and psychiatric symptoms [98]. In another study, character strength was found
to be positively associated with resilience compared to other factors (positive affect,
optimism, self-efficacy social support, self-esteem, and life satisfaction) [99]. Most
importantly, the identification of the character strengths utilized by physicians has
been investigated in an online study of approximately 200 hospital physicians in
Austria, Europe. Here, the following character strengths and virtues (in parentheses)
used by physicians were revealed as most critical for optimizing physician well-
being and work engagement (fairness, honesty, judgment, love) and burnout (fair-
ness, judgment) in the workplace [100]. Clearly, based upon this evidence, the
virtue of resilience requires additional investigation by the medical community as a
relevant component of well-being in order to assist their physicians to thrive as they

face ethical challenges and adversity within the medical workplace.
ddressing the Ethical Issues Associated with Physician Burnout

A
in Oncology: Assessment of Moral Distress, Respect of Values,
Learning Resilience Skills – Mindfulness Training
The case of Dr. A illustrates a common scenario: he recognizes that he is stressed

yet does not take the time to stop to understand what is happening, much less create
an action plan. Dr. A’s belief, although he hasn’t quite articulated it to himself, is
that while he realizes that he is at risk of burnout, he doesn’t know how to prevent it
or address the symptoms. His case represents a common situation for physicians in
cancer care. Because many clinicians did not have burnout prevention included in
their training, it is worth naming common tacit assumptions and strategies that do
not work [71]. Many physicians assume that burnout occurs when they have relin-
quished all freedom, everything he has to his work, and that when a fixed quantity
of energy is used up that burnout becomes inevitable. In addition, many physicians
during training experienced attitudes from role models that the ideal approach to
cope with stress is to “tough it out” and that physicians need to deal with these
issues on their own time. The strategies that result from these erroneous but com-
mon assumptions are that burnout should be approached by working longer, and
harder, not admitting stress self, and addressing colleagues mostly by venting
behind their backs. None of these strategies are effective – they simply compound
the problem. Preventing burnout proactively and addressing established burnout
needs to be addressed at the individual level and system level [71]. At the organiza-
tional level, institutions (academic centers, private practice) have an important role
in recognizing burnout and its ethical impact on overall well-being, assessment is
key, engagement of leaders and physicians in collaborative action planning is criti-
cal; promotion of learning skills that prevent burnout, and improvement of practice
environment and culture.
A Call for Assessment and Intervention Within the Organization
Efficacy research examining the impact of individual and organizational burnout

interventions found that institutional interventions are more effective than individ-
ual approaches [101–103]. Recognition and implementation of strategies designed
to reduce practice-related burnout and moral stress, uphold physician ethical stan-
dards and values, and foster moral resilience in organizations are needed to increase
well-being, rekindle professional engagement, and redefine ethical culture.
Moreover, the support of organizational leadership plays a significant role on the
professional satisfaction and burnout of physicians [48–50]. Organizational change
is key, and approaching resilience is based upon upstream, early intervention.
Clinician well-being is influenced by personal resources and work demands;
Table 7.5 Assessment and intervention within the organization

1. Organizational duty to the physician: respect for values, supportive culture,
communication, flexible work schedules
2. Assessment of the ethical work climate and moral distress
3. Improving physician well-being: enhancing moral cognition and action – mindfulness
training
4. Building community and peer relationships
therefore, fostering resilience for common challenges faced by physicians would be

of benefit for building self-awareness. To address workplace issues, the assessment
of burnout and the physician’s perception of work demands and workplace engage-
ment factors is a critical first step. It is vital to prioritize individual-skill building and
evaluate physician burnout, work-life factors, and moral distress over time. Routine,
longitudinal assessment of burnout and well-being using well-validated measures is
essential. Data should be utilized to engage clinicians and leaders on fostering com-
munication regarding salient issues for problem-solving and intervention to ensure
an ethical climate. Enhancing physician autonomy is critical. Workflow changes
(e.g., team-based care, less administrative tasks) are crucial. Burnout impacts the
organization, the entire team, and most importantly the physician. Yet, physician
burnout provides an opportunity for the medical community, including the cancer
community, to prioritize oncologist physical and emotional well-being.
Consequently, the cancer organization, with leadership’s support, should prepare,
plan, and implement interventions to build a supportive, ethical work climate to
restore resilience utilizing optimal, evidence-based programmatic interventions and
aid in building community and peer relationships (Table 7.5).
rganizational Duty to the Physician: Respect for Values

O
and a Supportive Ethical Culture
As an initial step to addressing this challenge, organizations must recognize the key
drivers of burnout and satisfaction in physicians. Although multiple factors adversely
impact physician well-being, the six work-life dimensions must be assessed: work-
load, work efficiency, control/flexibility, values alignment, meaning in work, and
work-life integration [39, 40]. The organization is responsible for the provision of
practical work-load/productivity expectations, an efficient practice environment,
oncologist input into practice decisions, and physician flexibility/control over their
work [12]. Organizations should uphold and respect the essential personal and pro-
fessional values of physician values as they fulfill their obligations to patients.
These organizations have an ethical obligation to provide essential informational
resources to physicians, such as oncologists, to fulfill their duty of providing quality
oncology care. Quality improvement devoted to enhancing physician safety is key
involving the design of flexible work schedules to promote physical resilience;
prioritizing overall well-being (e.g., sleep, nutrition) is vital [50]. Offering opportu-
nities for individual oncologists to focus on, some portion of their time, on the
aspect of work that provide meaning and purpose (e.g., a specific type of cancer,
education, supportive end-of-life care, clinical trials, quality improvement, admin-
istration), rather considering them as homogenous “clinicians,” is also critical for
the preservation of physician engagement in the long term [104]. Practice structure
and organization (e.g., call schedule, hospital coverage arrangements, office work
hours, vacation coverage) can either promote or harm efforts at improving and max-
imizing work-life integration [71].
Assessment of the Ethical Work Climate and Moral Distress
Addressing moral distress involves the cultivation of ethical, compassionate occu-

pational environments. Ethical, occupational environments are measured using the
Hospital Ethical Climate Survey to evaluate perceptions of the current workplace
mechanism supporting ethical practice [54]. Also, routine moral distress assessment
is critical to ensure an ethical work climate exists in oncology [105–107]. The Moral
Distress Scale-Revised (MDS-R), a 21-item instrument, assesses the individual’s
perceptions of hypothetical scenarios causing moral distress in two areas: (1) fre-
quency of the encountered work situation and (2) intensity of moral distress [107].
If moral distress is addressed, empirical evidence confirms that physician, and spe-
cifically the oncologist, introspection and team reflection arise yielding enhanced
interpersonal understanding [57]. Organizational commitments to physicians are
paramount in resolving moral distress.
Improving Physician Well-Being
Organizational interventions are critical mechanisms to addressing physician well-

being and fostering resilience [93, 108, 109]. Professionally empowering the oncol-
ogist to thrive, overcome adversity, and positively adapt to stressors within the
clinical environment is essential for cultivating resilience, including moral resil-
ience [88, 93]. As described above, resilience promotes well-being by strengthening
the oncologist’s vitality, self-efficacy, engagement, and the ability to cope. Team-
centered interventions can contribute to improving physician well-being. Individual
burnout interventions have been implemented at the organizational level [102, 103,
110]. These train-the-trainer interventions should be strongly encouraged as an ethi-
cal response for physician care. For example, well-accepted, empirically validated,
efficacious approaches such as mindfulness-based stress reduction (MBSR) and
cognitive behavioral therapy address unhelpful thoughts and fears to foster self-
compassion [111–114].
Enhancing Moral Cognition and Action: Mindfulness Training
Recent evidence suggests that morality is a multifaceted system of principles and

values which is executed through a dynamic physician-environment interaction
[115]. In fact, based upon traditional Buddhist practice and outcomes from biopsy-
chological and neuroscience research, the development of a “mindful state” fosters
an awareness of morally related internal and external environmental and situational
cues. These cues promote the emergence of moral cognitive awareness of ethical
conflict, reasoning to problem-solve, and cognitive processes leading to prosocial
moral action to address ethical conflicts and dilemmas. This application along with
other experimental psychological analyses examining the impact of mindfulness on
ethics, virtues, and character strength expands current thought that mindfulness
mediation is only relevant for the improvement of psychological well-being and
cognitive skills [116].
In contrast to cognitive-behavioral techniques that center on the content and
restructuring of thoughts, mindfulness meditation traditionally involves placing
purposeful attention on the process of thoughts [117, 118]. For physicians, the rel-
evance of mindfulness is that it offers training to change how they deal with multi-
ple demands, the constant pressure to multitask, and habits that keep them focused
on the cognitive skills used clinically. To date, two seminal studies indicate that
mindfulness training for practicing clinicians can have an effect on burnout, empa-
thy, and well-being for clinicians [117, 118]. It is worth noting that mindfulness
brings full attention to the present moment, rather than distraction, and that not all
forms of mindfulness have been comprehensively studied.
Fostering Community and Peer Relationships
Cancer organizations should strive to support an enhanced, collaborative commu-

nity [119]. The ability for a clinician to connect with other clinicians at a personal
level, in a way different from their typical clinical duties – either with family,
friends, or colleagues – has also been identified in research aimed at identifying
components of well-being. Mutual sharing of perspectives from peer physician col-
leagues alleviates moral distress. Peer support is an effective, meaningful resource
designed to promote institutional resilience [48–50, 120]. It enhances the oncolo-
gist’s professional development by enhancing mastery of clinical interactions [119].
The value of peer support lies within the oncologist-oncologist camaraderie, accep-
tance, and compassionate understanding gained [71, 120]. A deeper connection to
self, patients, and colleagues develops from shared experiences explored through
various perspectives centering on issues of dying, suffering, or grief [120–122].
Organizations foster peer relationships in times of crisis through community-
building; prioritizing workplace factors (i.e., enhancing workflow); virtual peer
meetings; physician-driven meditation groups; and telephone support [123, 124].
Peer support is beneficial for addressing moral distress for considerable systemic
challenges without immediate solutions [119–121]. Moral distress can be rectified
in a trustworthy environment where physicians are encouraged to prioritize
well-being.
Rebuilding Local Culture in Medicine
For physicians, whose practices have changed from self-run small businesses to
large managed systems where they are employees, the issue of work culture repre-
sents an important transition [124]. Physicians who are adjusting to having their
work defined and structured as employees, negotiating with payers in new ways,
mandates for quality and documentation that more complex than ever, are dealing
with change management, leadership challenges, and reimbursement changes that
have changed significantly how physicians regard each other as colleagues. In addi-
tion, the shift of medical care, including cancer care, to a team-based model means
that physicians form new kinds of collegial relationships with nurses and other spe-
cialists. As medical care undergoes continued restructuring, the importance of
rebuilding a community of practice that connects physicians as committed clini-
cians will require that individual clinicians think bigger than the organizational
roles they are assigned to the community of colleagues they want to practice, learn,
and care for patients with. As individual clinicians, physicians may not possess the
ability or power to change a situation like that – yet physicians do each have a
responsibility to advocate and participate in building the kind of culture that ensure
that they do their very best work and offer the optimal, ethical care for patients.
Conclusion
To date, burnout and moral distress have intensified in medicine impacting the phy-
sician’s emotional health due to the ethical dilemmas encountered as they address
patient needs and administrative tasks. Yet, unaddressed burnout has the potential to
damage and harm this physician-patient relationship. Advocacy is critical for aware-
ness, education, and promotion of the plight of the physician in an open communi-
cation forum to restore professional fulfillment within the organization. Supportive,
ethical climates can be developed and enhanced through community collaboration.
Moreover, the organization has a fiduciary duty to commit to the care of the physi-
cian’s physical and emotional health, uphold physician values, and foster moral
resilience and overall well-being for a long term. In fact, the medical community
(leadership, administrators, organizations, professional societies, ethicists, policy-
makers) must commit to this fiduciary duty by promoting a moral institutional cul-
ture by addressing the needs of the physician and ultimately sustaining the future of
the workforce. Now is the time, more than ever.
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Euthanasia and Medical Assistance
in Dying as Challenges for Physicians’ 8
Well-Being
Luigi Grassi, Karandeep Sonu Gaind, Tristan Nash,

and Rosangela Caruso
Introduction
The inviolability of life and prohibition for doctors to end it are ethical tenets that
inform the entire medical culture, codified since Hippocrates, in fourth century
B.C. Most likely, the Hippocratic code interpreted the best practice of the period,
as a primordial and long-lasting manifestation of the natural law. Then as now,
physicians were called to act in accordance with the non-maleficence principle
(primum non nocere) (see also Chap. 1), avoiding by all means damage to their
patients. The validity of natural law has been reiterated in human history, enduring
time to the point of influencing the Declaration of Human Rights [1, 2]. In this
light, doctors feel the moral duty to act with the purpose of reducing their patients’
suffering.
In many areas of medicine, however, especially palliative medicine, the themes
of death with dignity have been examined both from the perspective of palliation as
L. Grassi (*) · R. Caruso

K. S. Gaind
Governing Council and Division of Adult Psychiatry and Health Systems, University of
Toronto, Toronto, ON, Canada
Department of Psychiatry, Humber River Hospital, Toronto, ON, Canada
World Psychiatric Association, Geneva, Switzerland
T. Nash
University of Wales Trinity Saint David, London, UK

114 L. Grassi et al.
intended by the World Health Organization (WHO)1 and also from the perspective
of hastening the patient’s death to put an end to his/her suffering, as a form of care.
Within this framework, the questions about what physicians are allowed to do or not
to do in order to care for people in terminal phases of physical disease (e.g., cancer,
lateral amyotrophic sclerosis) has been the object of an ongoing and contentious
moral debate. Several questions arise with respect to this: are physicians allowed to
use all the possible ways to reduce suffering of patients, including use of drugs that
will hasten death? When physicians withhold-withdraw life-sustaining medical sup-
port in a dying person in whom nothing therapeutically effective can be done, are
they killing by intention? If so, is there any difference between omission (i.e.,
withholding-withdrawing treatment) and action (i.e., actively and intentionally ter-
minate the patient’s life by an act such as a lethal injection or in helping a terminally
ill person to end his/her life)? This has opened the door to the debated problem of
euthanasia (EU) and physician-assisted suicide, more recently defined as physician-
assisted death, medical-assisted death, physician assistance in dying (PAD), or med-
ical assistance in dying (MAiD).
Besides the moral matter, physicians have therefore to practically deal and
compete with the complex situation to put an end to a person’s life or to help him/
her to do so. This understandably can give rise to intense feelings of pity, empa-
thy, responsibility, or guilt and put a strain on their capacity to override the
dilemma between ideal concepts of justice, care and reality. Even when a doctor
is rationally convinced that deciding to put an end to one’s severe suffering is a
fundamental right of the person, this conflict, innate in the medical profession,
maintains the potential to generate a profound distress and undermine emotional
stability and well-being.
In this chapter we will examine some of the literature regarding the problems of
EU and MAiD and concentrate our attention on the potential emotional implications
and consequences on physicians and healthcare providers, including moral distress
(“an adverse psychological/emotional reaction to the inability to do what one
believes is morally required” is highly present in end-of-life care context, as a con-
sequence of the morally charged nature of the decisions to be taken [3] (see details
in Chap. 8)) and other psychological disorders, although the literature on this is
quite fragmented and sparse.
1
The World Health Organization (WHO) defines palliative care as the “approach that improves the
quality of life of patients and their families facing the problem associated with life-threatening
illness, through the prevention and relief of suffering by means of early identification and impec-
cable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Palliative care provides “relief from pain and other distressing symptoms, by affirming life and
regarding dying as a normal process; intending neither to hasten or postpone death; integrating the
psychological and spiritual aspects of patient care; and offering a support system to help patients
live as actively as possible until death […]” [52].
8 Euthanasia and Medical Assistance in Dying as Challenges for Physicians’ Well-Being 115
The Moral Debate around EU and MAiD
The problem of action and omission are important topics in medicine. In a general sense,
action relates to all the intentional activities (doing) that a physician may perform to a
patient; omission relates to the intentional decision to not act (not doing or stop doing)
to the patient. EU, MAiD, and also palliative sedation are part of the former, while
withdrawing-withholding treatment is part of the latter, as summarized in Table 8.1.
Without going into the details of palliative sedation and withdrawing-withholding,
it is important for the purpose of the aims of this chapter to concentrate attention on
the issues related to EU and MAiD. The moral debate about these practices is
extremely vast, with those explicitly against both practices and those supporting
them as morally acceptable.
Regarding the first group who opposes the practices of EU and MAiD and con-
siders these immoral, thus non-legalizable, it is claimed that religious and secular
traditions uphold the sanctity of human life. This group argues that society and
medicine have to preserve human life and uphold suicide prevention underlining
that there is an important difference between passively “allowing to die” and actively
“killing.” Therefore, neither EU nor MAiD is morally justifiable. In this sense, med-
icine is definable by its devotion to a single and clearly stateable purpose: healing
and conserving health and life since in the doctor-patient relationship stands the
moral duty of the preservation of “the most intimate, most personal, and most
humane uses of technology—the helping, caring, and curing of vulnerable, anxious,
dependent, and trusting members of the human community” [4] (page 24). Therefore
it is vicious and immoral for a physician to act intentionally in order to destroy even
vestigial integral functioning of her patient [5]. As a further argument, patients, as
individuals, have also obligations (e.g., to their family, social context including phy-
sicians, nurses, and the society in general) as long as they are alive. These obliga-
tions limit their rights, and if patients may refuse medical treatment they do not have
the right to be killed, since this, in the reciprocity of the doctor-patient relationship,
Table 8.1 Definitions about acts and omissions in medicine

1. Palliative sedation (formerly defined as terminal sedation): administration of drugs with
the intention to reduce refractory symptoms of suffering, even if the intervention may
hasten the death of the patient (principle of double effect)
2. Active euthanasia: Causing the death of a patient by administering a lethal drugs
(a) Involuntary: Causing the death of a patient without his or her consent when he or she
is competent to give consent
(b) Nonvoluntary: Causing the death of a patient who has irrevocably lost – Or never
had – The capacity for competence, so without any consent from him/her
(c) Voluntary: Causing the death of a patient at that person’s voluntary and competent
request
3. Medical assistance in dying (physician-assisted death or physician aid in dying or
physician-assisted suicide): Intentionally helping a person to end his/her life by
administering or providing drugs for self-administration, at that person’s voluntary and
competent request
4. Withdrawing/withholding life-sustaining supports, sometimes defined (but many rejects
this term) as passive euthanasia
would mean that physicians have a duty to kill [6]. Those of this view would argue
that EU or MAiD violates the Hippocratic Oath’s directive of “nor shall any man’s
entreaty prevail upon me to administer poison to anyone.”
In an opposite position are those endorsing the practices of EU and MAiD and
considering those practices moral, thus legalizable. They claim that everyone (not the
society, not the family) is the owner of his/her own life (including death, as part of the
process of life). Thus, as an autonomous, rational, and self-aware individual, his/her
decisions, including those about time and circumstances of death, should be respected
(e.g. [7, 8]), since giving everybody the right to have a good death through EU or
MAiD should be acceptable as a universal principle. It can consistently be willed as a
law that everyone ought to obey, as the only rules which are morally good are those
which can be universalized.2 From this perspective there is no reason to consider it
morally wrong to benefit the patient by giving him/her a shorter, less painful life rather
than having him/her endure a longer, more painful one, exactly as it is for amputating
a leg which may be done for the person’s own good [9]. These argumentations con-
firm the need to reconcile the misunderstanding about the good (i.e., life) and the bad
(i.e., death), since the opposite can be true, with death being a greater good than living
in suffering.3 Furthermore, if a right to live exists, this does not mean just to exist but
to have a life with dignity and values, since a life without dignity is not life anymore.
For these reasons those of this view see the practices of EU and MAiD as morally
permissible. They would argue that the Hippocratic Oath’s directive that “I will take
care that they (the sicks) suffer no hurt or damage” supports helping people end their
life if it helps them avoid prolonged suffering. A further argument to support the legal-
ization of EU and MAiD is to dissolve the distinction between deaths caused by
actions and death caused by omissions. In certain circumstances it is thought to be
permissible to allow a person to die. If no morally significant difference can be found
between deaths caused by omissions and deaths caused by actions, then, by extension,
there are grounds for allowing for death caused by actions.4
2
Through this perspective, I, as a competent adult in a terminal phase of an illness, should have the
right to die when and how I want to and to choose the timing and manner of my death, including
the right to accept or refuse treatment that will prolong my death (thus my agony), since it is
immoral to allow to prolong a life that has lost its dignity. On these premises, prohibiting EU and
MAiD drastically limits the rights of personal liberty and prevents intervention aimed at solving
loss of independence, of sense of purpose and meaning, and functional capacities.
3
From a utilitarian point of view, deciding to put an end to life will make a severely ill patient hap-
pier (good death) than being constrained to a slow death in pain and existential distress (bad death).
From a libertarian point of view, if an action, such as EU and PAD, promotes the best interest of
everyone concerned and violates no one’s rights, then that action is morally acceptable.
4
In this sense James Rachels seeks to demonstrate that there is no morally significant difference
between deaths caused by omissions and death caused by actions by arguing that someone who
kills their young cousin by drowning them in the bath to benefit from an inheritance is equally
morally reprehensible as a person who intends to drown their cousin only to see them slip in the
bath and standby while they drown (p. 32). He further argues that letting a person die is a type of
action, demonstrated by the fact that we would consider a doctor blameworthy if he needlessly let
a person die. As Rachel argues, “it would be no defense at all for him to insist that he didn’t ‘do
anything.’” He would have done something very serious indeed, for he let his patient die (p. 34).
In relation to the welfare of physicians, we may instinctively feel that bringing

about death by omission places less of a psychological burden upon the physician
than death caused by an action. If we are to accept Rachels’ argument ([10], see also
note 4), then there are no good grounds for why this should be the case. However, it
may be that the perceived difference in the psychological burden highlights a moral
difference between cases where a death is brought about by an omission and cases
where it is brought about by an action. Even if this is not the case, the difference in
the psychological burden between the two types of conditions is still a consequen-
tialist factor to take into consideration when assessing whether EU and MAiD
should be permissible.
As the scope of who could or should be eligible for EU or MAiD expands
beyond those who have terminal conditions to those who are not near the end of
life but suffering from nonterminal conditions (e.g., dementia, refractory depres-
sion or schizophrenia, severe personality disorders), this debate gets even more
complex. Some who may consider EU or MAiD acceptable for terminal condi-
tions oppose it for those with nonterminal conditions on various grounds. This
includes those who make ethical arguments in considering a moral distinction
between helping a dying person die peacefully and providing death to a non-dying
person, to clinical arguments regarding the unpredictability of prognosis of some
nonterminal diseases such as most mental illnesses, to social justice arguments
that psychosocial suffering of nonterminal patients risks vulnerable or marginal-
ized persons seeking death as a relief from poverty, loneliness, or other psychoso-
cial stressors [11–16].
Effects of EU and MAiD on Physicians
As said, while the theoretical debate about the ethical and moral implications and
contrasting positions on EU and MAiD is increasing, the practical aspects,
involving the medical profession, have determined a significant change in the
organization of the health system in the countries where these practices are legal,
including the Netherlands, Belgium, Luxembourg, Switzerland, Spain, Colombia,
Canada, Victoria (Australia), and some states in the USA (e.g., California,
Montana, Vermont, Colorado, Oregon, Washington, Washington DC, and
Hawaii). All have promulgated laws that allow physicians to provide a means by
which seriously ill patients, who encounter specific criteria, may be assisted in
ending their own lives [17–22]. Also, in six of the countries where MAiD is cur-
rently legal, mental disorders are also accepted as conditions for which MAiD
may be granted, and in four of these countries, MAiD in minors with mental
disorders is also accepted [11].
While the aim of these laws is to preserve patients’ self-determination in the face
of severe suffering and terminal pain, and prevent experiences of loss of dignity, the
psychological and moral implications of end-of-life care procedures on physicians
can be extremely complex, especially when the themes of direct actions, namely,
EU and MAiD, are at stake and need to be explored [23].
In fact working in some contexts, such as oncology, intensive, and palliative care
units, but also, as said, more recently psychiatry or geriatrics, poses healthcare pro-
fessionals under a moral strain: clinicians may literally feel that they have another
person’s life “in their hands,” with doctors expressing feelings of powerlessness and
isolation, being profoundly adversely stricken and shocked by the suddenness of the
death [24]. Furthermore, these areas require physicians to manage the tension
between a twofold responsibility: on the one side, professionals are expected to act
with the aim to save the patients’ lives; on the other they feel an ethical obligation
to maintain patients’ quality of life acceptable and dignified [25, 26]. This renders
the ethical decision-making process a demanding task for clinicians, with conse-
quences on their well-being and, in certain circumstances when distress is particu-
larly intense and enduring, on their capacity to provide an acceptable quality of care
for the patients. The main physician’s role in EU and MAiD determines the need to
understand the psychological impact of these practices on them. In effect, changing
the direction of care from preserving and extending life to helping someone end
it – although with the aim of preserving dignity and autonomy of patients – can be
felt as a detachment from the fundamental values of medicine to heal and promote
human integrity, thus producing critical effects at a deep emotional level [24].
Early descriptions from the countries where EU and MAiD have a long tradi-
tion, such as the Netherlands, highlighted that many physicians who had practiced
EU stated that they would be extremely reluctant to do so again [27]. Different
results were presented in a further report [28] of a sample of 405 physicians (gen-
eral practitioners, nursing home physicians, and clinical specialists) interviewed
between 1995 and 1996. All of them had experience in having performed formal
EU (i.e., administering drugs with the explicit intention of ending a patient’s life at
the patient’s explicit request), MAiD (described by the authors as assisted suicide,
i.e., prescribing or supplying drugs with the explicit intention of enabling the
patient to end his or her own life), life-ending without an explicit request from the
patient (i.e., administering drugs with the explicit intention of ending the patient’s
life without a concurrent explicit request from the patient, that is, involuntary or
nonvoluntary EU), and alleviation of pain and other symptoms with opioids (i.e.,
administering drugs in doses which the interviewees believed large enough to have
a probable life-shortening effect). In 52% of the cases of hastening death, physi-
cians had feelings of comfort afterward, which included feelings of satisfaction in
44% and of relief in 13% (higher among those who performed MAiD in compari-
son with other forms of hastening death). However, feelings of discomfort, referred
to as emotional (28%) or burdensome (25%) or heavy responsibility (13%), were
also reported (42% of the sample). Discomfort was higher among those who per-
formed EU (75%) or MAiD (58%) in comparison with those who performed invol-
untary/nonvoluntary EU (34%) or alleviated pain and other symptoms with opioids
(18%). Almost all physicians were willing to perform EU (both voluntary and
involuntary/nonvoluntary) again in similar situations, 5–7% had doubts, none had
regrets, while 43% of those performing voluntary euthanasia would like to have
support afterward in comparison with 16% of those ending the life of the patient
without his/her explicit request.
More recently, Evenblij et al. [29] reported the findings from a study of two
groups of physicians, the first who refused a request for EU or MAiD and the sec-
ond who granted this request. Concerns about specific aspects of the EU and MAiD,
such as the emotional burden of preparing and performing the practices, were com-
monly reported by physicians who refused and who granted a request. The large
majority of physicians reported contradictory emotions after having performed EU
or MAiD. Also, pressure to grant a request was mostly experienced by physicians
who refused a request, especially if the patient was old, had a life expectancy of less
than 6 months, and did not have cancer. Among primary care physicians, it has been
shown that different emotions emerged during EU, specifically tension (before EU),
loss (during EU), and relief (after EU) [30]. The relationship with the patient, the
sense of personal loneliness, the role of the family, and the pressure from society
also emerged as main issues physicians had to deal with, underlining that the need
to have sufficient emotional space and time to take leave adequately from a patient
is important for physicians. In a Belgian study carried out on nurses, however, moral
distress was more related to providing futile and inadequate care than EU and
believing to hasten an unconscious patient’s death by increasing morphine in geri-
atric end-of-life care [31].
In the USA, a study carried out among randomly selected oncologists who
reported participating in EU or MAiD showed that about half of the physicians felt
comfort from having helped a patient with these practices. One quarter regretted
performing EU or MAiD, and 16% reported that their emotional burden adversely
affected their medical activity [32]. In a mail survey of 81 physicians who had per-
formed EU or MAiD, Meier et al. [33] reported the following responses pertaining
to the most recent prescription for a lethal dose of medication or a lethal injection:
18% of the physicians reported being somewhat uncomfortable with their role in
writing a prescription, and 6% were very uncomfortable with the lethal injection. In
further study, [34] the impressions of 35 Oregon physicians who had performed
MAiD were examined and showed that they often felt unprepared and experienced
apprehension and discomfort before and after receiving requests (e.g., concerns
about adequately managing symptoms and suffering, not wanting to abandon
patients, and incomplete understanding of patients’ preferences, especially when
physicians did not know patients well). Even when they felt they had made correct
choices, many physicians expressed mixed feelings about what they had been
through and uncertainty and a sense of estrangement, as it appears from some of
their responses: “But my thoughts are about the fact that I know that it is a very dif-
ficult thing as a physician…I wonder if I have the necessary emotional peace to
continue to participate.” “I find I can’t turn off my feelings at work as easily…because
it does go against what I wanted to do as a physician.” In some other cases, physi-
cians report a feeling of entrapment and a moral conflict arising from the patient’s
request to be helped to die: either they agree to perform EU or MAiD, and then they
will struggle with profound emotional consequences, or they retreat, and this will
make them feel as if they have abandoned their patients in despair [34]. This aspect,
regarding countertransference, can furtherly complicate the emotional context
related to end-of-life care.
More data are however needed regarding the personality and the emotional con-
ditions of physicians, considering, for example, that in a country where EU and
MAiD are not permitted, such as Italy, agreement with both practices among gen-
eral practitioners was correlated with non-Catholic religious affiliation, inexperi-
ence in treating terminally ill patients, and the burnout dimension of
depersonalization [35].
A further important issue raised as a problem not solved yet at this level regards
the new educational needs for both medical students and physicians who will be
called to act in MAiD. As Gewarges et al. [36] underline, there is little published
research on the impact that such deaths have on physicians who provide MAiD, or
on others who are indirectly involved, and there is still virtually no literature to
guide MAiD education in clinical practice. This is in clear contrast with the cumula-
tive evidence regarding the impact of patient death on medical students, residents,
and attending physicians that suggests a need for supported discussion and debrief-
ing to process and reflect on the emotional experiences that follow patient death
[36]. With respect to this, Patel et al. [37] showed that dealing with requests for
hastened death determined clinicians indicating their responses in seven domains:
policies, professional identity, commitment to patient autonomy, personal values
and beliefs, the patient-clinician relationship, the request for hastened death, and the
clinician’s emotional and psychological response. These needs are in line with data
indicating that although participation in MAiD requires a large investment of time
and it is emotionally intense, physicians rarely receive support from colleagues,
while it is more common to discuss emotional aspects of their experiences with their
spouses [34].
The recent extension of the practice from terminally ill patients to other contexts
(e.g., patients with severe mental illness or dementia) is posing further challenges.
Again the moral debate has to do with the principle, accepted by countries that
approved its application, that offering MAiD to a patient with a mental illness who
suffers unbearably, enduringly, and without prospect of relief, such as schizophre-
nia, can be ethically acceptable, since the seriousness of the suffering of the patient
does not depend on the cause of the suffering; thus a distinction between physical
(or somatic) and mental suffering should be rejected [38–40]. Data regarding the
experience of these countries where MAiD is possible in psychiatry are accumulat-
ing, although, to our knowledge no literature have investigated the psychological
effects on physicians, especially considering the difference in anticipating the death
to a person who is terminally ill and a person who is physically health but psychiat-
rically ill.
Areas Requiring Further Study
While studies have focused on the characteristics of patients seeking EU and MAiD,
there is a relative dearth of research on the characteristics of physicians providing
EU and MAiD and how this may influence the impacts of EU and MAiD on physi-
cian health and well-being. Several studies suggest that patients seeking EU and
MAiD often do so for reasons of existential distress and that their views on assisted
dying are mostly determined by psychosocial traits and beliefs rather than disease
severity or symptom distress [41–43]. While different authors have conflicting
views on whether EU and MAiD provide hope to patients seeking relief from a state
of suffering, or lead to despair by signaling there is no hope of improvement [44],
little is known about providing hope in the context of EU and MAiD. While some
have suggested “false hope” in providers might lead them to recommend “invasive
and useless” treatments instead of EU or MAiD, others question whether similar
pressures of “empathic frustration and feeling powerless to help while witnessing
patients’ continued sufferings, coupled with the desire to be useful, [could] lead
other providers to support MAiD) as a way to feel helpful themselves” [45]. What
drives physicians to participate, or not participate, in EU and MAiD is naturally
likely to impact their reactions to EU and MAiD, and it would be important to fur-
ther study this to understand impacts on physician well-being. This would be par-
ticularly important in jurisdictions where EU and MAiD are provided for
non-end-of-life conditions, such as mental illnesses. Uncertainty of predicting irre-
mediability, conflation of psychosocial suffering with illness suffering, and chal-
lenges of differentiating nonterminal patients seeking EU and MAiD from suicidal
patients suicide prevention initiatives could be anticipated to have complex effects
on physician well-being and mental health [46].
Conclusions
The changing scenario in the approach to death and dying, with an increasing num-
ber of countries endorsing and legally approving the practice of EU and MAiD, has
determined the need to examine in more detail the psychological implications and
consequences for physicians practically performing or involved in both practices.
As Stevens [24] suggested the shift away from the fundamental values of medicine
to heal and promote human wholeness to the pressure on and intimidation of doctors
by some patients to assist in suicide has significant emotional impacts on clinicians.
Participation in EU and MAiD can in fact create significant conflict: from one side
it can contrast with perception of professional roles, responsibilities, and personal
expectations and the duty to preserve life, and from the other it can perfectly attune
to the sense of helping the patient and not abandon him/her, according to the duty to
relieve suffering.
In spite of the importance of these themes and this issue to medical practice, as
recently indicated by Kelly et al. [47], this is a largely neglected area of research
with limited studies to date that indicate 30–50% of doctors describe emotional
burden or discomfort about participation and significant, ongoing adverse personal
impact in about 15–20%, while findings also identified a comfort or satisfaction in
believing the request of the patient was met. Since responding to a request for has-
tened death can be an overwhelming task for clinicians, it is necessary to have an
approach that takes into consideration the legal, personal, professional, and patient
perspectives to provide a response that encompasses all the complexities associated
with these delicate areas of the medical profession [37]. This highlights the need to
address the responses and impact on clinicians and the support for clinicians dealing
with this challenging area. The effect of countertransference in the doctor-patient
relationship may influence physician involvement in these practices should be also
examined.
This is particularly true for the further challenging area of the application of EU
and MAiD in nonterminally (somatically) ill patients, that is, those with dementia
or psychiatric disorders or just tired of living. Dutch data show that the majority of
physicians would grant a request for EU or MAiD in a patient with cancer or another
physical disease, while about one third found this conceivable in patients with psy-
chiatric disease, early-stage dementia, or advanced dementia, and one quarter for
people tired of living [48]. Similarly in Canada, while over 70% of psychiatrists
support the availability of MAiD in some situations, only one third support MAiD
for mental illnesses in the absence of a terminal condition [49]. Risks have been
raised in this area, given the complex societal and medical interactions involved,
including the possibility that the slippery slope is a reality already. For example,
economic pressures are a problem in most health systems, and providing MAiD is
far more cost-effective than providing medical care to chronically ill or end-of-life
patients, with estimates of between $34.7 million and $138.8 million in annual sav-
ings under current Canadian MAiD policies (which currently allow MAiD only for
conditions where death is “reasonably foreseeable”; the cost implications would be
greater if MAiD were expanded to other conditions) [50]. It has also been pointed
out that, as some of the people requesting EU or MAiD are likely to be a source of
usable organs for transplantation, their broad inclusion would strengthen the link
between EU and MAiD and organ donation, with potential damage of general trust
in medical, professional, and public health authorities [51]. The psychological
implications on physicians should be carefully examined, given the further conflict
for the role that physicians have in the health system and their moral boundaries
and duties.
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Moral Distress in Physicians
9
Diya Banerjee and Yesne Alici
Moral Distress in Physicians
Physicians operate in systems, like citizens in a republic, and inevitably conflicts

arise between the values and needs of the physician and those of the institution.
Much of the time, a reconciliation or compromise can be found, but when this is not
the case, these points of friction can create an internalized phenomenon generally
called moral distress. Healthcare systems have become increasingly complicated
and opaque, leading to mounting pressures and escalating stress in the physician
workforce. This chapter will provide an overview of moral distress in physicians
including definitions, common sources and constraints, as well as interventions with
specific examples from oncology and the COVID-19 pandemic.
Definitions of Moral Distress
There have been many attempts to define Moral distress since its introduction to the
literature in 1984 in Andrew Jameton’s work on nursing ethics. Jameton categorized
moral and ethical problems in the hospital broadly as uncertainty, dilemmas, and
distress. He described distress specifically as an experience that arises “when one
knows the right thing to do, but institutional constraints make it nearly impossible
to pursue the right course of action.” [1] Following this description, additional
refinements emerged. In 1993, Jameton added an axis of time, describing initial
D. Banerjee (*)
New York, NY, USA
Y. Alici
Weill Cornell Medical College, New York, NY, USA

128 D. Banerjee and Y. Alici
moral distress or the “feeling of frustration, anger, and anxiety” experienced in

these moments and reactive distress which occurs when the initial distress is not
acted upon [2]. Additional formulations more explicitly link the concept of moral
distress with psychological and physiological suffering. Both features of this term,
morality and distress, carry their own sense of vagueness which makes pinning
down a clear taxonomy challenging.
One definition from 2016 that attempts to capture multiple aspects of moral dis-
tress involves three components or domains, much like contemporary understand-
ings of burnout in physicians. These domains include negative attitudes one
experiences, one’s perceived involvement in a situation, and perceived moral unde-
sirability of the situation [3]. Each one of these areas has shades of nuance; negative
attitudes can be subdivided by the type, appropriateness, intensity, timing, and con-
sequences of attitudes. Perceived involvement allows for type and degree of engage-
ment, and perceived moral undesirability can encompass the source, degree, and
accuracy of perception.
To apply this definition to the scenarios they involve, let us examine a particular
case in end-of-life care in oncology, taken from a narrative review on this subject.
The quote below refers to the practice of performing aggressive care at end of life,
specifically futile resuscitation attempts [4].
It is so distressing. You are beating someone’s body, and often as the medical provider, you
personally are beating their body… It is very difficult to go home at the end of the day and
be like, ‘I just did this. I just battered someone today.’ (US, PGY3).
In this brief snapshot, the different facets of moral distress are reflected. This physi-
cian perceives themself as an agent of violence, likely accompanied by self-directed
shame and anger and exemplifying internalized negative attitudes about their own
behavior. The personal involvement of the physician is more explicitly highlighted
here, as is the moral undesirability of the act, evident in the use of the verb “beating”
and “batter” to refer to chest compressions.
Sources of Moral Distress
The sources or root causes of moral distress are defined by the literature in three
broad categories: clinical situations, internal constraints, and external constraints.
The distinction between the three can be artificial, and these categories span both
the individual and institutional scope of medicine. There are, however, a few com-
mon sources of moral distress that are repeatedly referenced, specifically care near
the end of life – which can prolong or hasten the dying process – interprofessional
practice in a hierarchical medical system, fear of litigation, hostile and unprofes-
sional work environments, economic and societal factors adversely affecting patient
care, and organizational values and ethical climate [5]. A number of qualitative
studies have helped define these common causes of moral distress and the psycho-
logical and at times physical consequences on clinicians [6]. Figure 9.1 illustrates
9 Moral Distress in Physicians 129
• Waste
• inappropriate resource allocation
• Harm
Clinical • futile treatment, inadequate pain relief,
situations disregarding patient wishes
• Poor care
• lack of continuity, conflicting duties, inadequate
informed consent
• Powerlessness
• self doubt, lack of assertiveness, socialization to
Internal follow others
Moral distress • Knowledge deficits
constraints • lack of understanding of situation, lack of
knowledge of alternatives, inability to identify
ethical issues
• Organizational deficits
• inadequate staffing, poor administrative support,
tolerance of disruptive/abusive behavior
• Additional interests
External • policies/priorities that conflict with care needs, fear
constraints of litigation, compromising care to reduce costs
• Hierarchies
• Poor communication among team members,
differing inter and intraprofessional persepctives,
lack of collegial relationships
Fig. 9.1 Root causes of moral distress
these factors that contribute to the root causes of moral distress, adapted from quan-
titative research done on this topic [7].
Trying to quantify moral distress in a clinical environment can be challenging
and is likely a shifting target tied to the time and context of a surveyed population.
In one study from 2013, a single health system was surveyed for frequency and
intensity of moral distress for common clinical scenarios across several disciplines
including nursing, trainees, physicians, social workers, and chaplains [8]. All groups
rated moral distress an intensity higher than frequency, though causes varied by
discipline. Physicians were noted to have a higher mean moral distress intensity
compared to other groups, though it is worth noting that the response rate was
approximately 5% for physicians.
Impact of Moral Distress
The consequences of moral distress in clinicians can be hard to clearly delineate,

though it seems from the very definition that the impact is predominantly a negative
one. One model of the influence of Moral distress over time involves the concept of
moral residue, which is the distress that remains after a situation has resolved. This
residue can accumulate with repeated incidents and lead to a crescendo or breaking
point, after which the providers’ moral integrity erodes and can result in
desensitization and withdrawal in the face of other moral aspects of care [9]. In
terms of behavioral consequences, moral distress has been recognized as an impor-
tant factor that can prompt clinicians to leave a job or even leave the field [10].
Quantitative measurements have been developed, the first and most widely used in
the USA being the Moral Distress Scale [11]. This scale was first created in 2001
and sought to characterize the frequency and intensity of distress in a variety of
clinical situations. It underwent a revision in 2011 to include measures of moral
residue, and the scale was made more applicable to a range of clinical practices
[12]. There are several challenges with both qualitative and quantitative studies of
moral distress, most notably differing definitions and inconsistent terminology,
methodological limitations, and cultural limitations.
Another common association with moral distress is burnout, and several studies
have looked at correlation between Moral Distress Scale scores and various burnout
inventories. One study of ICU nurses found that moral distress was a significant
predictor of all aspects of burnout [13], and another linear regression analysis of
ICU clinicians also identified moral distress as independently associated with burn-
out, particularly severe burnout [14]. As is discussed in other chapters, the impact of
clinician burnout has wide-reaching consequences for both providers and patients.
Burnout can lead to poor well-being and job turnover [15], unprofessional behavior
[16], decreased quality of care, and higher rates of medical errors [17]. These down-
stream outcomes add urgency to further study of moral distress.
Within the field of oncology, there are particular circumstances that are more
likely to engender moral distress in clinicians. In an ethnographic study, three fac-
tors were observed to foster conflict: delaying or avoiding difficult conversations
about poor prognosis, being caught between competing obligations, and silencing
different moral perspectives [18]. Talking about end of life is complex and challeng-
ing for clinicians and often hindered by a perception of death as failure, discomfort
around prognostic uncertainty, and challenging patient and family dynamics [19].
This often leads to delays in when and how treating teams address preparation for
end of life. A common example of competing obligations arises in shared decision-
making, when there may be incongruence between patient or surrogate autonomy
and clinician’s principles of nonmaleficence and beneficence. As an illustrative
example, competing obligations for a clinician could arise when a surrogate
decision-maker refuses pain medication for an incapacitated patient with severe
cancer-related pain [20]. Resolving scenarios like this requires nuance and an abil-
ity to weigh the patient or surrogate’s goals and values against the possibility of
doing harm by withholding analgesia. Lastly, differing moral perspectives can arise
within a team and particularly in cross-cultural situations. For example, in some
cultures, it is normative for family members to ask clinicians to withhold diagnostic
or prognostic information about cancer from the patient. Individual autonomous
medical decision-making is not universally considered the norm, and family mem-
bers may feel obligated to shield bad news from the patient [21].
This chapter thus far has addressed moral distress from an American perspective;
however moral distress is not isolated to one geographical location. There is an
increasing body of literature regarding moral distress in different countries with dif-
ferent healthcare systems [22]. Many of the themes remain the same; however there
are notable differences in cultural attitudes and resource allocation.
Moral Distress in a Global Pandemic
The eruption of global pandemic from SARS-CoV-2 (severe acute respiratory syn-
drome coronavirus 2) in late 2019 and throughout 2020 has brought shared moral
challenges [23]. The intense stress on medical systems has allowed for all of the
root causes of moral distress highlighted above to come to the foreground in the
domains of clinical situations and internal constraints and external constraints.
In the early phase of the pandemic in the USA, the lack of adequate resources to
provide optimal care was notable and led to challenging ethical questions around
appropriate use of these scarce supplies and fears of waste [24]. Further complicat-
ing the issue is incomplete and insufficient clinical knowledge about the efficacy or
futility of different interventions for this novel virus. For clinicians who had to make
choices about whom to expend resources on and why, there were – and continue to
be – many opportunities for moral conflict and distress. On an individual level, the
unknown and overwhelming nature of the disease engendered feelings of self-doubt
and inadequacy in treatment providers [25]. These presentiments may extend
beyond the clinical sphere, as physicians and nurses struggle to financially and emo-
tionally provide for themselves and family during times of danger and uncertainty.
In a survey of Chinese nurses, done around the peak of COVID-19 cases in Wuhan
(February 2020), mean scores of self-efficacy were low [26], below the T norms for
heterogenous adult populations [27], which may exemplify the subjective reality
described above.
External factors contributing to moral injury and distress during COVID-19
occur at broad cultural, systemic, and organizational levels. Throughout the pan-
demic, the guidelines and recommendations from governing bodies have shifted
and fluctuated in their attempt to balance individual care and community well-
being. One particularly poignant example in the USA is blanket visitor restrictions
for hospitalized patients, leading to the distressing reality of hundreds of thousands
of Americans dying alone [28]. Furthermore, clinicians are potential vectors of dis-
ease spread, and institutional policies aimed at quarantining exposed individuals
can further strain limited staffing despite increasing need. On the societal level, the
pandemic has highlighted underlying injustices, with disadvantaged communities
experiencing delayed access to testing, lack of insurance, higher existing chronic
disease burden, provider bias, as well as disproportionate economic hardship from
prolonged quarantine [29]. With these entrenched inequities leading to higher rates
of mortality in certain populations, clinicians can feel complicit in a broken system.
These clinical, internal, and external factors together provide a moral crucible for
clinicians today, with distress stemming from psychological injury and conflicted
feelings of responsibility and involvement.
Interventions for Moral Distress
Having looked at the definition of moral distress and seen ways it can occur in par-
ticular contexts, the next step is to identify different interventions. Interventions can
be targeted at the root causes and components of moral injury and distress, on both
individual and organizational levels. These include fostering resiliency in individual
clinicians, providing support (such as interdisciplinary ethics teams and psychiatric
services) and moral leadership and ethical culture.
Individual interventions for moral distress tend to emphasize the concept of
“moral resiliency.” Resilience is viewed as a process rather than a trait and refers to
an ability to adapt to or recover from stress, trauma, or loss. Moral resilience par-
ticularly focuses on the moral aspects of human experience and involves having a
sense of moral identity, responsiveness, and flexibility in complex ethical situations,
exercising conscientious objections, and seeking meaning in situations that threaten
integrity [30]. One of the first steps toward achieving this response involves an edu-
cational framework that introduces fundamental values, cultivates self-awareness,
and develops personal efficacy. There hasn’t been a consensus ethical curriculum so
to speak, though some institutions have developed educational programs with
didactic and high-fidelity simulations such as the Mindful Ethical Practice and
Resilience Academy in the Johns Hopkins school of nursing [31].
Areas of additional study in cultivating individual moral resiliency include the
use of mindfulness techniques and improving understanding of coping styles.
Mindfulness meditation is adapted from a school of cognitive behavioral therapy
developed and validated in the treatment of depression and anxiety [32]. This tech-
nique of pausing, noticing, and connecting to one’s inner resources can help culti-
vate emotional regulation in the setting of adversity [33]. Another avenue of
self-study involves better understanding of coping styles in the face of moral dis-
tress, which can vary between individuals and even interprofessionally. In one
examination of nurses and physicians in an oncology practice, four dominant ways
of coping were identified (thoroughness, autonomy, compromise, and intuition) all
of which have their own strengths and weaknesses and can impact the functioning
of a team [34].
On a more systems level, there are interventions that can reduce moral distress
such as the implementation of ethics consultation services and mental health inter-
ventions for healthcare practitioners. Ethics committees are a common way of
addressing ethical issues in US hospitals; however their role can often be variable
[35]. In the context of moral distress, however, ethics consultation can serve a pur-
pose beyond providing expertise in challenging clinical situations. They can be
instrumental in maintaining the “moral habitability” of an organization, by support-
ing staff and leadership and fostering interprofessional collaboration [36]. Even
more directed interventions, such as unit-based ethics conversations or development
of a moral distress consultation service, can focus on identifying root causes of
moral distress in units and systems [37]. Anticipatory mental health interventions
may also play a role in supporting clinicians encountering moral distress.
Organizations could provide psychological support for staff, for example,
• Moral Leadership
Institutional • Ethical climate
• Ethics teams
• Clinician support
Teams/Units • Identifying root causes
• Mental health resources
• Education
Individual • Mindfulness techniques
• Individual coping styles
Fig. 9.2 Interventions for moral distress
addressing burnout and depression resulting from moral distress with trauma-
informed therapy resources [38]. Peer groups have also been studied as an interven-
tion for work-related stress [39] and provide a safe space for clinicians to reflect on
challenging situations and develop supportive relationships.
Lastly, moral leadership and organizational culture can be powerful tools to
address moral distress. Leadership in this context is distinct from management and
refers to the capacity of a leader to model values and interact with and motivate their
followers. In business literature, a leader’s moral development is congruent with
employee moral development which is positively associated with job satisfaction
[40]. To bring this concept to the realm of moral distress, an ethical work climate
can decrease many of the extrinsic root causes leading to moral distress. For exam-
ple, an institution’s ethical priorities can influence how physicians approach resus-
citation decision-making near the end of life, which can lead to overly aggressive
care and subsequent moral distress [41]. The overall goal of aligning leadership and
organizational and individual values within a shared mission can foster an ethical
workplace with moral resiliency. In summary, a problem as challenging and protean
as moral distress requires multiple types and levels of intervention as shown below
in Fig. 9.2.
Conclusion
While the particular stressors weighing on clinicians may vary depending on field
of practice and time, the impact of moral distress appears to remain the same. There
has however been a burgeoning interest in this phenomenon as a vital factor in phy-
sician well-being, and an international effort to better understand and address moral
distress has emerged. In this chapter, we discuss the definitions of moral distress,
review the hypothesized causes, examine the impact in different clinical contexts,
and outline different types of interventions. Further scholarship will hopefully illu-
minate more aspects of this difficult topic and provide new avenues of understand-
ing and reasons for hope.
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Embitterment in the Workplace
10
Michael Linden and Christopher P. Arnold
Introduction
Burdens, strains, demands, social conflicts, daily hassles, severe negative life events,
and even life-threatening events are common experiences in life. This is also and
even more so true for physicians. They often have to work around the clock. They
have to cope with terrible illnesses and death, which may even be contagious. They
have contact with many, and very different, and sometimes even aggressive persons.
They often have to work under insufficient and unsupporting conditions. Persons in
this profession show by selection or training often great hardiness and resilience and
even love their job. An important resilience factor which helps to endure all these
adversities are ethical beliefs. Patients are in need of help and physicians feel that
their role and destiny are to help. The guiding rule for physicians since ancient times
has been “the patient first.”
Given the importance of such ethical basic beliefs for their self-definition and
daily work, violations in this area can have severe psychological sequelae. Breach
and disrespect of basic beliefs is a severe negative life event, which can challenge
one’s self definition, the justification of what one does or has done for so many
years, and the motivation to respond to ongoing demands. If a person has cared for
patients and worked for the institution, irrespective of personal costs, and the answer
is criticism, blame, downgrading, exploitation, and thanklessness, then this is expe-
rienced as injustice. Injustice is aggression, which is typically answered with
M. Linden (*)
Berlin, Deutschland
Charité University Medicine Berlin, Department of Psychosomatic Medicine, Research
Group Psychosomatic Rehabilitation, Berlin, Germany
C. P. Arnold
Charité University Medicine Berlin, Department of Psychosomatic Medicine, Research
Group Psychosomatic Rehabilitation, Berlin, Germany

138 M. Linden and C. P. Arnold
counteraggression. But, if this does not result in compensation and the reinstalment
of justice, then helplessness and in the end embitterment will emerge.
Injustice is a special, frequent, and important burden in the medical field, and
embitterment is a natural response. Nevertheless, this problem and this emotion
have so far found almost no attention in science, the organization of institutions, and
individual care for caregivers. This chapter describes how injustice can occur in
medical practice, how embitterment can develop, and how to prevent it.
Social Conflicts and Injustice in the Workplace
Workplaces are in most cases characterized by complex social relationships. Positive

are group integration, social support, and positive self-experience. On the other
hand, there are also negative aspects and burdens, such as conflicts, rivalries, bully-
ing, demands and sanctions by superiors, negative group interactions, and aggres-
sion from customers or other third parties [1].
A special burden which has found much attention is injustice in the workplace.
There is “organizational injustice” caused by structures and the organization of the
workplace which leads to unfair treatment of employees. Examples are gender
inequality, racism, favoring of friends, unfair promotion rules and pay, or in general
an “effort-reward imbalance.” This includes “informal injustice” which is defined as
dishonest communication with workers, which goes hand in hand with decisions
that are not justified. The aggressor is the “system” but translated by persons who
represent the system. Therefore, the risk of “personal” insults and humiliations is
higher than of organizational injustice in general [2–4].
Organizational Injustice and Exploitation

Physicians have high ethical standards, which first of all includes care for
their patients. They stay with the patient as long as needed.
This is abused by the employers when an insufficient workforce is hired
because of the expectation that physicians will take care of the patient even
though this results in long shifts which are often not even paid adequately.
This ethical responsibility to assist a patient in need is being exploited by
the organization and can be described as “organizational injustice.”
Furthermore, there is also “personal” or “interactional injustice” which describes

unfair treatment of employees by people with whom they are in direct contact. This
includes interactions with colleagues, supervisors, and clients. Interactions are con-
sidered unfair when an employee is treated without respect, with downgrading
statements and personal attacks, which has found much attention under the heading
of “bullying” or offensive and aggressive surveillance [5–8]. The scale for abusive
supervision [7] includes items, such as the following: “I need to tell my manager
how to split my working hours,” “My manager gives me no space to organize things
10 Embitterment in the Workplace 139
for work as I think it is right,” “My manager increases the pressure when I take
breaks from work,” “My manager tries to exert influence over decisions concerning
my work,” “I am closely monitored by my manager at work,” “My manager knows
what I do every day at work.”
Interactional Injustice and Humiliation

In particular in medicine and hospitals, physicians are closely supervised by
superiors. An important goal is to prevent harm for the patient and educate
young physicians. This requires looking for inadequate treatment and giving
advice and instructions which often include criticism.
This can be insulting and downgrading, especially when the criticism may
be wrong, phrased in harsh words, and expressed in the presence of col-
leagues or even patients.
Injustice can also be caused by customers, clients, and patients [9, 10]. A general
saying is that the customer is always right and decides what should be done. The
person who is addressed by the customer is often not responsible or in command,
like a train conductor when it comes to delays. However, customers then may exhibit
rude behavior as if the other person was their servant. Some use verbal abuse and
sometimes even become physically aggressive. A scale for measuring injustice by
customers [10] includes items such as the following: (the customer) refuses to listen
to you, interrupts you, accuses you of not delivering, starts irrelevant discussions,
questions your abilities, shouts at you, uses condescending language, and commu-
nicates aggressively with you.
Injustice by Patients
Physicians work in direct social contact with patients. Patients need help,
care, support, and even emotional affection by physicians.
At the same time, patients can behave as if the physician was their servant
or would be responsible that they are ill and do not recover. They have idio-
syncratic ideas about what should be done, blame the physician when things
do not work, become aggressive, or may even start legal disputes.
Responses to Workplace Injustice
The general consensus in the scientific literature is that injustice in the workplace is
associated with psychological distress. This has become apparent in regard to gen-
eral psychological well-being, psychosomatic symptoms, or life satisfaction.
Concomitant emotions are anger, depressive symptoms, sleep problems, or increased
alcohol consumption. Workers whose salary was reduced suffered more from sleep
disturbances than employees whose salary remained unchanged. Relational injus-

tice and an effort-reward imbalance have a negative impact on sickness absence,
while job interventions designed to improve respective working conditions have the
potential to reduce the level of absence [2, 4, 11–16].
Injustice is experienced as aggression and often answered by counteraggression.
When physical aggression is banned, social aggression is an alternative. This can be
directed immediately at the primary aggressor, such as a colleague, superior, or
customer [17–20]. In a meta-analysis injustice emerged as a predictor of aggression
in the workplace [21].
Counteraggression
Aggression and hostile behavior toward physicians by a patient, the hospital
management, or other persons can lead to counteraggression. The patient is
reacting uncooperatively, and the physician may become cynical, mock the
patient, retreat from the patient, or even start especially painful interventions,
e.g., when removing a band-aid.
When a physician feels that he is being treated by the organization in an
unfair way, counteraggression can involve inner emigration, dysfunctional
work output, or absenteeism.
Aggression against colleagues or superiors can have different faces. The

workplace aggression scale [22] has statements such as the following: “I have
passed on harmful information about my superior,” “I said something to offend
my manager,” “I threw something at my manager,” “I pushed my manager.”
Employees can also use aggression, retaliation, and sabotage against customers
after unfair treatment. A scale developed by Skarlicki et al. [10] lists examples of
anti-customer aggression and sabotage in call centers, like deliberately putting
the customer on hold for a long time, intentionally forwarding the customer to
the wrong authority, or telling the customer that the damage has been repaired
even though this did not happen.
Due to the special conditions in the workplace, counteraggression cannot
always be exercised in public, so the worker has to use hidden strategies. This can
be clandestine revenge or sabotage against the institution or the person who is
seen as the cause of injustice or humiliation. Examples of deviant behavior in the
workplace are as follows: “the worker stole property from work without permis-
sion,” “waste of the work environment,” “insulting someone at work,” or “leaving
the workplace too early, without permission.” Passive-aggressive reactions are
another form of counteraggression. These are characterized by internal emigra-
tion and resignation when there is no direct path of confrontation or when no
specific person can be identified as the harmeing person. The consequence is an
inner aversion and reduced commitment, poorer performance, and reduced pro-
ductivity [10, 22, 23].
Embitterment in the Context of Work-Related Conflicts
When injustice is accompanied by humiliation and breach of trust when it refers to

areas in life which are important for the self-esteem of the person and when it is
associated with helplessness, then embitterment is a natural reaction [24–27].
In one of the first publications on severe embitterment, a case of organizational
injustice was described [28]. It is of an East German social worker who had been
employed for many years in a church-owned nursing home, who had done every-
thing to keep the institution running during the turmoil of the German reunification.
He was happy and proud of what he had achieved. When finally another church-
affiliated company took over, he was the first person who was fired in the course of
management reorganization. After that he retreated from all social contacts and
even declined new job offers.
Another published case [29] of embitterment in response to “interpersonal injus-
tice” is of a woman who had been working as a saleswoman in a small supermarket
for years in close and friendly connection and solidarity with colleagues. When an
external auditor visited the supermarket and falsely accused her of stealing money,
she responded with acute dissociation, immediately left the supermarket, ended all
contacts with her colleagues, stayed jobless, and even thought about killing herself.
The accusation of the auditor did not hurt her much, but the betrayal by her col-
leagues who stood silent and did not come to her defense when she was denounced
as thief was hurtful.
The common underlying psychology in both cases is that expectations in justice
were severely violated. If doing everything for the foster home and even saving its
existence, then you deserve acknowledgment. Being fired instead is highly unjust
by the organization. It does not matter that the top management made this decision
based on general and important considerations on financial issues and need of a
younger workforce. In the case of the saleswoman, it is the breach of trust. If you
were closely working together with colleagues, always ready to help while main-
taining a friendly relationship, then it is highly unjust to be left alone when one is
being attacked by an external person. This has led to violations of basic beliefs and
concepts of oneself and other persons. An interesting point is that the victims were
“good” persons. They themselves acted according to social standards and therefore
expected that others do the same. The “good” employees are those who can be hurt
by injustice, and their strengths makes them vulnerable. Those who care about their
job can be hurt in this area of life, while those who believe that the family stands
above everything are vulnerable in this area. Embittered reactions happen when
important values, assumptions, world definitions, and self-definitions are ques-
tioned because of injustice. These basic values are the same ones that motivate
people, control behavior over the lifespan, and are necessary to be well-adjusted in
life and therefore also at work.
Embitterment
A physician was working in an understaffed and professionally mediocre
department of a hospital as deputy of the department head. His superior quit
the job and he took over the interim directorate. He worked for two and man-
aged that the department achieved a new perspective, so it was recognized as
a good medical institution and even made a small profit. This motivated a big
company to take over the hospital. Instead of acknowledging the achieve-
ments of the physician and making him the new head of the department, they
hired another person and dismissed him. Consequently, he spent all his time
and money to unsuccessfully sue the new hospital owner, up to the point of
bankruptcy. He did not look for a new job which he easily could have had.
Embitterment is an emotion which is known to everybody. Nobody needs to read

a psychology book in order to understand the meaning and phenomenology of
embitterment. Similar to other emotions like anxiety, it can occur as transient feel-
ing after a discussion with a colleague [27]. There is stimulus bound embitterment,
when for years this emotion is elicited, when a certain critical event is mentioned,
while there are no psychological problems in all other areas of life. There may be
embitterment-prone personalities, who are easily offended for minor reasons.
Finally, there is the “posttraumatic embitterment disorder” [26, 28] where a single
critical event causes the person to become ill from 1 minute to the other, withdraw
from social contacts, and suffer from repeated intrusive memories of what has hap-
pened, is downhearted, broods in thoughts of revenge, and ponders thoughts of sui-
cide or even murder suicide.
There are several studies on the prevalence and correlates of work-related embit-
terment. Karatuna and Gök [30] investigated employees from the public sector,
including 23.9% who were labeled as victims of bullying. The experience of bully-
ing was found to be highly correlated with feelings of embitterment, intrusive
thoughts, and negative moods. In a study by Ege [31, 32], 91.5% of persons who
reported conflicts at work showed elevated embitterment scores. This suggests that
some victims of workplace conflicts, who are presently diagnosed and treated as
depression or phobia, are in fact suffering from embitterment. In an online survey
by Michailidis and Cropley [33] with 337 respondents, results showed that proce-
dural injustice and over-controlling supervision were significant predictors of
embitterment and that embitterment significantly contributed to the prediction of
increased affective rumination and reduction in detachment. Embitterment was a
significant mechanism through which organizational injustice and over-controlling
supervision exerted their effect on affective rumination which is indicative of insuf-
ficient recovery from work. In a 6-month longitudinal study [34], the authors found
that perceptions of distributive injustice, informational injustice, and employees’
perceptions on supervisory over-control significantly predicted embitterment at
follow-up. Only the relationship between employees’ perceptions of supervisory
control and embitterment remained significant after controlling for baseline levels
of embitterment. Sensky et al. [35, 36] reported data on persons attending an occu-
pational health department in a single NHS Trust. There were 30% of attendants,
mostly nurses, who had an elevated embitterment score which shows the impor-
tance of this psychological reaction. Staff showing embitterment were significantly
more likely to be on sickness absence although they were not depressed. They rated
procedural justice and organizational support lower than other staff. Sensky [37]
argues that embittered individuals are likely to appraise their work as demanding,
and because embitterment is intrusive and spills over into the person’s life outside
work, recovery from work is likely to be impaired. These complex interactions may
also explain why Muschalla et al. [38] found in persons attending a psychiatric mili-
tary hospital that embittered persons showed impaired contacts with others and
reduced group integration. Eckert et al. [39] found in a survey on nurses that aca-
demic nurses showed less embitterment than non-academic nurses, while there was
no link between embitterment and material aspects, e.g., salary. They conclude that
material aspects seem to be less important than the human need for respect and
recognition.
revention and Improvement of Embitterment

P
in the Workplace
The relation between injustice, embitterment, and dysfunctional behavior and prob-
lems at work suggests that we should be nice to each other, not insult each other, and
be fair and just. Everybody will agree with these statements. General rules of good
conduct in the workplace and of transparency of decisions of superiors can undoubt-
edly help. The problem is that human beings are not always nice, that there are very
different views on what can be called “just” or “unjust,” and that organizational and
management decisions depend on aspects which cannot always show consideration
for the expectations or even needs of individual employees. It is therefore necessary
to find ways of coping with inevitable stress, conflicts, and injustice. This requires
the capacity to find emotional distance from the critical event [40].
Psychological capacities which help to cope with unsolvable problems, irretriev-
able losses, and irreparable negative experiences are described under the heading of
wisdom. There is a comprehensive psychological literature in this regard [41–43].
Wisdom includes several subdimensions, such as factual and procedural knowl-
edge, contextualism, value relativism, change of perspective, empathy, relativiza-
tion of problems and aspirations, self-relativization, self-distance, perception and
acceptance of emotions, serenity, forgiveness and acceptance of the past, uncer-
tainty tolerance, and long-term perspective. Wisdom has been proven to be a resil-
ience factor when confronted with stressors of any kind or unsolvable problems in
life. Wisdom can be learned and trained [44]. It can also be an interesting approach
in corporate health management programs [45]. If there are persons who are over-
whelmed by embitterment and suffer from posttraumatic embitterment disorder,
professional help is required. This can also be based on principles of wisdom psy-
chology to induce a cognitive reframing and change of perspectives, to turn away
from the past to the future, and to forgive [46]. The first step in any case is to recog-
nize embitterment in all its facets [31, 32].
Conclusion
Injustice is a frequent social stressor, which is often also experienced by health

workers. It is typically associated with downgrading and breach of trust. As the
belief in a just world is an inborn mighty psychology, injustice results in strong
counteraction. If it associated with helplessness, embitterment can emerge, a burn-
ing negative emotion, causing much suffering to the person and the environment
and also stimulating dysfunctional behavior. Injustice and the development of
embitterment should therefore be recognized early on, and preventive measures
should be taken.
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Prevention of Burnout Through
Resilience, Wellness Programs, 11
and Civility in the Work Environment
Caroline M. Kissane and David W. Kissane
Introduction
When emotional resilience is overwhelmed to produce exhaustion, detachment, and

loss of professional accomplishment, the resultant burnout is characterized by
ICD-11 as an “occupational phenomenon.” [1] Preventing burnout requires
responses at both the individual and at the institutional level, taking account of orga-
nizational culture, stage of training, specialties, and gender. The surge in the chal-
lenge of burnout is termed an “epidemic” or “crisis” because the prevalences are
rising to alarming levels.
The British Medical Association 2019 survey sampled over 4300 clinicians
including 1400 medical students and reported the prevalence of a formal diagnosis
of a mental health condition in the last 12 months by age group, from 27.9% in
medical students and junior doctors around 25 years of age to 8.4% for doctors older
than 64 years [2]. This pattern of greater burnout in medical students, interns, and
residents was evident in a 2004 review of 15 studies (1983–2004) [3], confirmed in
Australia by the beyondblue survey of 14,063 physicians and medical students in
2013 [4] (high exhaustion in 48% of those under age 30 years compared with 11%
of those over 61 years), and acknowledged in a recent 2018 review of medical stu-
dent and resident burnout [5].
In the USA, the 2018 Physicians Foundation survey of Practice Patterns and
Perspectives [6] assessed burnout by appraising the morale and satisfaction of 8774
C. M. Kissane
Department of Paediatrics, Royal Children’s Hospital, Parkville, VIC, Australia
D. W. Kissane (*)
University of Notre Dame Australia and Cunningham Centre for Palliative Care Research,
St Vincent’s Hospital, Sydney, NSW, Australia
Cabrini Health Psycho-oncology Unit, Monash University, Malvern, VIC, Australia

148 C. M. Kissane and D. W. Kissane
physicians. Some 55.3% reported somewhat or very negative professional morale,

and 61.6% reported feeling somewhat or very pessimistic about their future. While
78.7% describe the doctor-patient relationship as the most satisfying aspect of med-
icine, the three least satisfying concerns were as follows: (1) 39.2% rated the design
of the electronic health record as least satisfying; (2) 37.7% decried the burden of
regulatory and insurance oversight; and (3) 66% reported that patient care was
adversely impacted by third-party authorizations, which took clinical autonomy
away from clinicians. Many of these perspectives are uniquely resultant upon the
US medical insurance culture.
Given such high prevalences with risks for poor care provision, medical error,
medicolegal consequences, and physician suicide, this chapter focuses on preven-
tion, spanning the promotion of wellness and resilience in the individual to organi-
zational approaches that enhance the workplace.
Interaction of the Person with the Workplace
Pioneers of the measurement and study of burnout, Christina Maslach and Michael
Leiter identify the goodness of fit between each person and their work environment
as crucial [7]. Both components, the workplace and the individual, potentially con-
tribute, yet more is accomplished by an initial focus on environmental factors [7].
Key workplace factors include the scope of the workload, the extent of initiative and
control the employer permits, and the recognition that is provided for every contri-
bution, fostering a sense of teamwork and workplace community, ensuring equity
and justice, and creating an alignment of the common values that motivate the work-
force. Maslach and Leiter start with the concept of civility in the workplace, where
a culture of appreciation is built to acknowledge each person’s effort, teamwork is
nurtured, role ambiguity is avoided, and workloads are balanced. Then the health
workforce can tackle challenging patient problems in an optimal environment,
which cultivates competence, compassion, and care provision by all. Let us review
each of these key dimensions in more detail.
Workloads
West and colleagues conducted an important systematic review and meta-analysis

in 2016 to examine interventions that decreased burnout [8]. Organizational inter-
ventions helped more than ones aimed at the individual, and foremost among these
was reduced duty hour requirements for rosters and shifts. Burnout was signifi-
cantly reduced by 12% when resident hours were reduced across six varied cohort
studies [8], creating a more sensible work-life balance. Practices of time off after
night duty, alternating rosters of day and night coverage, and sensible total hours are
all features of these equitable policies.
11 Prevention of Burnout Through Resilience, Wellness Programs, and Civility… 149
Permitting Initiative and Control
Ambitious leaders in top-ranked medical institutions often invite the creation of

productivity goals, whether as income earned, patient numbers consulted, research
grants won, publications generated, or discoveries recognized. Tension can readily
develop between such a culture of productivity and the need for self-care [9].
Respectful performance reviews that affirm contributions, honor the person’s role
and support of the team, thank them for their service, and then invite their goals to
be developed for the next year sustain the necessary civility and respect. The clini-
cian is encouraged to take their own initiative and feel very much in control of the
work they set out to do.
Recognition and Reward
Workplaces that cultivate annual awards for performance and contribution instill
pride in their workers and deepen the motivation that succeeds. Role models are
inspiring to others, while team awards also acknowledge the common effort.
Strong leaders know that every person on their team gains from expressions of
thanks and gratitude for a job well done. Much more is achieved by praise than
criticism.
Community
Workplaces that hold regular social events, foster collegiality, and normalize relax-
ation away from work build the cohesion of the team, including a sense of pride to
belong. Training days and regular educational fora also build this teamwork, allow-
ing for peer review and mutual support as clinical reviews are undertaken and
evidence-based approaches to quality care are sought by all. Strong institutions
achieve a healthy balance between education and service, taking opportunities for
junior staff to educate others as a pathway to learning themselves.
Equity
Gender bias, with unequal training and job opportunities in some specialties for
women, has been an obvious example, but studies draw attention to rostering and
on-call schedules, reimbursement, access to administrative support, taking annual
leave, and arranging coverage for conferences and holidays as other examples
where issues of equity can arise [10].
Values
Acquisition of skill and clinical competence is essential to the practice of medicine

and is a fundamental core value. Compassionate care is then supported by empathic
communication, which is an acquired skill learned through communication skills
training and a very important response to the challenges of working with difficult
patients [11, 12]. The ethic of support in the workplace is best exemplified, however,
when a clinician is sued for medicolegal issues. This is a remarkably frequent life
event in some countries, with specialties like surgery and obstetrics topping the lists.
This is identified as highly stressful, partly because lawyers advise their medical
clients to not discuss the case, the resultant silence denying support and assistance.
Institutions do well to routinely arrange support via a senior mentor from another
discipline so that debriefing can occur and the clinician is not left to feel alone.
Preventive Strategies for Students and Young Physicians
Selection Strategies for Medical School Entry
Greater movement to mature age entry for medical schools, with consideration of
personality traits, gender, learning styles, and coping strategies, appears pertinent.
One systematic review identified Chinese males developing more exhaustion,
depersonalization, and suffering than females [13], while different cultures revealed
the reverse, exemplified by Saudi females [14]. High levels of neuroticism, avoidant
coping, and inflexibility to change are negative predictors in contrast with openness
to new experience, conscientiousness, agreeableness, active problem-solving, dura-
bility, and determination to persevere [15, 16].
Fostering Social Support
Building a strong personal support base through family, friends, and collegial rela-
tionships is crucial [17]. Peer support is developed through the use of problem-
based learning groups in medical schools and debriefing about complex cases in
small groups in the workplace. In private life, functional and meaningful relation-
ships sustain a healthy work-life balance. For many, the spousal relationship is a
primary and vital source of support, which therefore needs to be prioritized, nur-
tured, and sustained in a mutually responsible manner [10].
Nurturing Self-Efficacy and Resilience
Cultivating self-awareness, capability, self-belief, and values consistent with

medical life can empower behavior change that fosters resilience, leadership,
agility, collaboration, and creativity. A reflective capacity is essential. Strong con-

nections, capacity for trust, open communication, and decisiveness foster the
capability that ensures success. Mentoring can be one pathway that facilitates
such development.
Structured Mentoring Programs
As we move from the student into the development and wellness of the young doc-
tor, mentoring becomes an important activity to guide each person’s maturation.
Medicine is so large that generic mentoring is challenging, but as soon as individu-
als gain a sense of direction and interest in specialization, this becomes feasible.
Good colleges and specialty training programs both normalize and structure this
mentorship by making it a responsibility of a training director to ensure that effec-
tive matching of trainee and mentor occurs [17]. Trainees ought to nominate a senior
doctor they admire, reflecting a goodness of fit between the interests and career path
of the mentor and mentee. Mentoring creates a reflective space in which a young
physician can consider and review their training program, needs, aspirations, and
journey on the path to becoming a full-fledged specialist in the area of medicine
they want to practice. Their work-life balance and overall wellness are gentle com-
ponents of the process.
Mentoring is, of course, a different process to direct clinical supervision of a
young doctor, where specific skills are taught to achieve competency in entrustable
professional activities. Effective supervision is a sine qua non for every reputable
medical training program.
Management of Rostered Hours for Residents
Evidence shows that working greater than 50 hours per week is associated with
increased mental health disorders and suicidal ideation in medical staff [18]. As a
modifiable risk factor to reduce burnout, several countries have legislated maximum
working hours per week as well as limits on continuous working hours per day and
required length of break between shifts. The use of forward rotating shifts from day
to evening to night shifts has been found to allow better adaptation of sleep cycle
patterns [19]. The use of “Hospital At Night” teams with senior medical and/or
nursing staff leads to ensure even distribution of workload as well as increased sup-
port and educational opportunities for junior staff and has been found to improve
staff well-being as well as patient safety [20]. Rostering of protected time to com-
plete administrative and educational duties can also reduce unpaid overtime and
improve job satisfaction [21].
Wellness Programs to Prevent Burnout
The leadership of organizations must recognize that burnout is not the sole respon-
sibility of individual physicians, but rather there is a moral responsibility to address
it as a shared, systemic issue [21]. Good leaders champion the promotion of both
institutional and departmental approaches to wellness (see Fig. 11.1) through tar-
geted interventions and a culture of connection and mutual support, so that work-
life balance is integral to the ethos of the institution. In this section, we review
programmatic offerings that have proven helpful.
In response to the beyondblue survey data highlighting increased rates of burnout
in doctors, hospitals in Australia have embraced mental health and well-being
awareness days such as “R U OK?” and “Crazy Socks 4 Docs” to facilitate open
discussions among staff at all levels and improve knowledge of available support
services. Hospital grand rounds and junior doctor teaching programs have incorpo-
rated well-being sessions with motivational speakers such as physicians and high-
performance athletes discussing their own experiences of depression and anxiety
(see, for instance, https://www.ruok.org.au/ and https://www.crazysocks4docs.com.
au/) (Fig. 11.1).
Competent Meaningful Work
Dedicated commitment to ongoing education, training, and skill development is a

lifelong professional requirement [22]. Inbuilt here is recognition of each physician’s
unique abilities, so that their talent is directed to meaningful and fulfilling work [23].
In general, at least 20% of professional activity needs to target what is most meaning-
ful for any physician in order to significantly protect against burnout [24].
INTERACTION OF
PERSONAL &
ENVIRONMENTAL
DRIVERS OF
FUNCTIONING WELLNESS FUNCTIONING
WITH RESILIENCE WITH BURNOUT
• Goodness of fit in work role
• Staff well trained & resourced
• Competence In role • Fulfilment from work • Reduced quality of care
• Enthusiastic engagement • Nurturing & valuing ethos • Emotional exhaustion
• Dedication & commitment • Adaptable environment • Withdrawal & avoidant coping
• Work-life balance
• Active social support
Fig. 11.1 Resilient functioning in preference to burnout results from the interaction of personal
and environmental factors that promote wellness
Stress Management for Personal Wellness
Taking personal time to relax, pursue hobbies, disconnect from work, and enjoy
regular holidays empowers doctors to then engage at work with vigor and commit-
ment [25, 26]. Healthy sleep hygiene is one dimension; sensible use of alcohol is
another. Pursuit of a spiritually enriched life helps many. The practice of mindful-
ness has a growing evidence base in preventing burnout [27, 28].
Exercise Programs
Surgeons and proceduralists with an action-oriented mindset endorse the value of regu-
lar exercise in a hospital-based gymnasium as integral to their sense of wellness [10].
Team-based approaches to exercise routines in hospital staff are beneficial in prevent-
ing burnout and enhancing quality of life [29]. Yoga sessions appeal to some clinicians.
Balint Groups
Clinicians value debriefing about difficult patients, developing strategies and com-
munication techniques for responding to anger and criticism, and learning from
each other as peers who face similar problems [30, 31, 32]. These groups, named
after Balint, who first started these for general practitioners, have a strong evidence
base for preventive benefit [33, 34]. In a Comprehensive Cancer Center, for exam-
ple, discipline-specific peer groups (six to eight medical oncologists) supported by
a psychiatric colleague would meet bi-monthly over 3–4 years to share experiences
of challenging patients and mutually support one another.
Schwartz Center Rounds
The presentation of difficult and sometimes ethically challenging cases in which

clinicians reflect on their personal feelings and share reactions about what proved
demanding with their colleagues has proven helpful in building collegiality and col-
lectively acknowledging the way in which compassionate care impacts upon clini-
cians. A systematic review of ten studies of such rounds highlighted some, albeit
limited, evidence of their positive impact on both individuals and the institution’s
culture, their accessibility to all staff being clearly appreciated [35].
Buddy Systems
Buddy systems and near-peer mentoring programs help to support junior doctors
navigate stressful transition phases, such as from medical student to junior resident,
with guidance from doctors who have more recently gone through a similar
experience rather than senior mentors [36]. While these relationships can develop
informally through work interactions, formal systems that assign juniors to a near-
peer buddy can also help to provide a social connection for those new to a hospital
or geographical area. Mentors also benefit with further development of interper-
sonal, self-reflective, and leadership skills.
Workplace Education About Bullying and Sexual Harassment
Educational online programs are encouraged in many institutions to raise awareness

about zero tolerance approaches to unwelcome behaviors such as bullying or sexual
harassment. These preventive programs have the goal of elimination of such stress-
ors in the medical workplace.
After some Australian female surgeons spoke out publicly about their experi-
ences of sexual harassment during training and the negative impact that reporting
had on their careers due to the hierarchical system of medicine, the Royal
Australasian College of Surgeons established an advisory group to investigate and
address the issue [37]. The resultant “Operate with Respect” campaign acknowl-
edged the widespread significance of the problem and introduced new training mod-
ules, anonymous complaint systems, and free counseling services.
Recovery from Workplace Injury
Institutions usually engage a confidential Employee Assistance Program (EAP) [38]

through which counseling can be arranged for employees where work stress from
whatever reason is developing. A survey of 44 organizations supporting over 50,000
employees through EAP demonstrated strong satisfaction and organizational benefit
after workplace stress or injury [38].
Conclusion
Resilient clinicians result from excellent training in a specialty well suited and ful-
filing to them, so that they engage in outstanding patient care with enthusiasm, dedi-
cation, and compassion. Institutions who are blessed to employ these stellar
physicians reward and nurture them with a sensible work-life balance, adaptability
to meet their needs, and pride in their scholarship, teaching, and extraordinary
patient- and family-centered care.
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Cultivating Resilience and Preventing
Burnout: A Mindful Multipronged 12
Intervention Approach
Fernando Kawai and Daniel McFarland
Introduction
Exceedingly high rates of burnout in healthcare professionals across each discipline

serve as testament to this unfortunate state of affairs [1]. For oncologists specifi-
cally, the global incidence of burnout has increased drastically over the past decade
in the United States, Europe, and Australia [2–4]. While adverse mental states
related to clinical work is not a new concept and was documented even in the time
of Hippocrates, the degree to which this is taking place is alarming as noted in previ-
ous chapters [5].
There are evidence-based interventions to prevent burnout and relieve the work-
related mental health burden experienced by healthcare professionals. However,
understanding why interventions are effective, to what extent they work, and for
which clinical settings and which clinicians are all open questions. The data guide
curious and well-meaning clinicians and organization in certain directions but do
not provide clearly delineated, evidence-based pathways for all burnout scenarios.
Interventions to address burnout, depression, and other mental health maladies
associated with the clinical work of physicians are generally divided into those that
address the individual clinician versus those that address the operation of the orga-
nization, which of course also affect individual clinicians. The evidence reveals that
both are effective. Studies that incorporate both types of interventions (combinato-
rial studies) are rare but are particularly promising since burnout is essentially a
worker-work place mismatch.
F. Kawai (*)
Department of Medicine, New York Presbyterian Queens/Weill Cornell Medical College,
Flushing, NY, USA
D. McFarland
New York, NY, USA

158 F. Kawai and D. McFarland
This chapter is divided into Parts 1 and 2. Part 1 will provide a general overview
of the evidence for burnout interventions at both levels (individual and organiza-
tional). It will highlight interventions for individual clinicians and in particular the
use of mindfulness-based stress reduction and cognitive behavioral techniques and
how these may be incorporated into the context of organizational strategies to
reduce burnout. A review of consensus-based recommendations for organizational
initiatives to address burnout can be accessed from Shanafelt and Noseworthy [6].
Part 2 offers an example of an individual treatment plan to prevent or treat burnout
in a burned-out clinician that is inspired by the Buddhist perspective of mindfulness.
Formal mindfulness training is highly recommended but may require a significant
commitment by individual clinicians and organizations. While there is not a substi-
tute that provides the same evidence-based benefit, mindfulness techniques can be
incorporated seamlessly into one’s clinical practice. Part 2 offers many practical
suggestions that can be practiced and incorporated into an individual clinician’s day
to day routine with significant flexibility based on the needs of the clinician.
Part 1 Restoring the “Tragedy of the Commons”
The tragedy of the commons is an analogy from economics published in 1968 that
demonstrates how a shared resource such as a common area or town pasture becomes
overused when the self-interest of an individual or single entity is amplified to an
entire group acting similarly without regard for replenishing the resource [7]. In this
case, the commonly used resource from which individuals and society benefit is
physician well-being. The health of a community or a hospital system benefits from
the presence of resilient clinicians, but the cultivation of clinician wellness and
resilience is undermined by a dispersion of responsibility for replenishing this valu-
able commodity. Patients, hospital corporations, and society benefit from the tal-
ents, integrity, discipline, and hard work of those who enter the medical field and
cultivate its practice over a lifetime. Without proper nourishment and restocking,
this enviable and invaluable resource of clinician well-being, which buttresses pro-
fessionalism and the integrity of medical practice, can become compromised by the
effects of burnout and, most tragically, suicide.
The restoration of physician well-being has become a priority according to many
professional societies. The way forward is multifaceted and evolving. Interventions
should identify and incorporate root causes for burnout and address workplace envi-
ronments where the work-worker mismatch takes place. Consensus statements and
expert opinion describe how these problems begin insidiously and reinforce the idea
that addressing the root cause means making systemic changes, creating institu-
tional awareness and a culture around clinician wellness [6]. The vast majority of
interventions for individual clinicians focus on symptom reduction rather than
addressing root causes of burnout.
Several systematic reviews and meta-analyses provide organized and collective
assessments of intervention effectiveness and the strengths and weaknesses of dif-
ferent approaches [8–12]. Overall, efforts to reduce burnout and other clinician
12 Cultivating Resilience and Preventing Burnout: A Mindful Multipronged… 159
mental health maladies are effective and demonstrate small to moderate effect sizes.
Reduction in symptoms may be greater when examining depression/anxiety/dis-
tress outcomes and clinicians who were already experiencing mental health dys-
function (e.g., burnout). Subgroup analyses found that burnout interventions may be
more effective for practicing physicians over resident physicians and that organiza-
tional interventions may offer greater symptom reduction [8, 9]. Also, interventions
may demonstrate greater effectiveness for physicians in primary care disciplines
rather than subspecialized care. Of the individual interventions, those that use
mindfulness-based strategies and cognitive-behavioral techniques offer the most
benefit. These meta-analyses, which had slightly varying entry criteria, outcomes,
and targeted populations, also highlighted the limitations of applying static inter-
ventions across the varied landscape of medical practice.
Specifically, West and colleagues analyzed 15 randomized trials and 37 cohort
studies (2914 physicians) that evaluated interventions to prevent and reduce physi-
cian burnout [8]. Almost all study endpoints were reduction in burnout using the
Maslach Burnout Inventory (MBI). Both individual level and structural or organiza-
tional strategies resulted in meaningful reductions in physician burnout, but many
studies focused on only one element of burnout (i.e., burnout domain such as emo-
tional exhaustion, depersonalization, personal accomplishment) rather than an over-
all assessment of burnout. The effects of the interventions were similar between
randomized and observational studies although there was considerable variability.
Absolute reductions in burnout may seem modest (e.g., a reduction of 1–3 points on
the MBI was noted in the meta-analysis by West and colleagues [8]); however, it
should be noted that small changes in burnout scores by even 1 point on the MBI are
associated with meaningful differences in important adverse outcomes [13]. In
addition, clinicians with higher burnout scores in Emotional Exhaustion and
Depersonalization had even greater reductions in burnout scores. Half of the ran-
domized studies assessed resident physicians, and the majority involved a combina-
tion of small group intervention with duty-hour restrictions, while the cohort studies
involved mostly resident duty-hour restrictions.
A meta-analysis of interventions to reduce burnout in physicians conducted by
Panagioti and colleagues only evaluated controlled interventions across primary,
secondary, and intensive care physician practices (1550 physicians) looking at
Emotional Exhaustion (EE) of the MBI [10]. Of the 20 interventions, 12 were indi-
vidual based (MBSR, educational, communication skills, education) and 8 were
organizational (workload rescheduling or more extensively changed workflow), 10
were in sub-specialized care disciplines and 12 were with “experienced” physicians
only (not in training). Overall, they found a small but significant reduction in burn-
out (SMD = −.29) with EE scores decreasing from 17.9 (SD 9.0) to 15.1 (8.5).
Interventions directed at the organizational level were more effective than physician-
directed interventions (SMD = −0.45 versus −0.18). The difference was larger in
“experienced” non-trainee physicians and in primary healthcare settings but was not
statistically significant.
Petrie and colleagues analyzed eight intervention studies that evaluated changes
in distress, anxiety, depression, and suicidal ideation in 1023 physicians [9]. They
noted a lack of controlled studies at the organizational level, and only a few well-
controlled intervention trials were directed toward practicing physicians as opposed
to physician in training. Interventions consisted of variations of cognitive behav-
ioral therapy (CBT) and mindfulness and organizational changes (e.g., protected
time). The time commitments to the intervention varied significantly from 90 min-
ute in-person weekly group sessions over 16 weeks to receiving a letter of tailored
feedback after filling out an assessment entitled “self, relationship, and work” [14,
15]. A priori subgroup analyses found that group interventions were more effica-
cious than individual interventions (SMD 0.78 versus 0.39, respectively).
Interventions that were classified as CBT or mindfulness-based were more effica-
cious than a composite of “other” interventions (SMD 0.79 versus 0.46, respec-
tively). They found no difference based on type of control used and no significant
heterogeneity or bias. Some notable future directions included decreasing burden of
documentation, clarification and guidance of administrative tasks, replacing licens-
ing board questions with questions of functionality rather than diagnosis, encourag-
ing a participatory management style with physicians, and instilling a professional
ethos of self-care.
Melnyk and colleagues evaluated 29 studies that aimed to improve mental health,
well-being, physical health, and lifestyle behaviors of physicians and nurses but
found that the wide array of outcome measures precluded quantitative pooling and
a meta-analysis [12]. Of note, this review also included studies evaluating outcomes
in nurses. They found that mindfulness and CBT-based interventions were effective
in reducing stress, anxiety, and depression. They highlighted studies that incorpo-
rated deep breathing techniques, gratitude practices, and interventions to increase
physical activities (e.g., pedometers, visual triggers, health coaching with texting).
These systematic reviews found that interventions that incorporate mindfulness-
based stress reduction (MBSR) are particularly efficacious on the individual level
and are also effective for reducing compassion fatigue [16]. Mindfulness can be
defined as “paying attention in a particular way on purpose, in the present moment
and non-judgmentally” [17]. A mindful clinician could be described as one who
“attends in a nonjudgmental way, to his or her own physical and mental processes
during ordinary everyday tasks to act with clarity and insight” [18]. The appeal of
mindfulness in clinical practice is that it allows clinicians to “listen attentively to
patients’ distress, recognize their own errors, refine their technical skills, make
evidence-based decisions, and clarify their values so that they can act with compas-
sion, technical competence, presence, and insight.” However, authenticity and hon-
esty with oneself are required for sustaining mindfully oriented clinical practice,
which is quickly undermined when coupled with an overly demanding or inefficient
workplace. Variations of cognitive behavioral therapy also help create self-awareness
and limit self-sabotaging behavioral patterns and harmful automatic beliefs. While
these interventions are effective for individual clinicians, organizational interven-
tions that alter the structure of practice in some way may be more durable and effi-
cacious. The most common types of organizational interventions are work-hour
restrictions (e.g., for resident physicians in training) but may include the cultivation
of workplace relationships, changes in call schedules, or providing group account-
ability for alleviating burnout.
Importance of Leadership
In addition, hospital and clinical leadership is an integral component to instituting

sustainable changes that may ameliorate burnout or enhance clinician competence
[6]. For example, the American College of Physicians has introduced mandates to
increase meaningful practice and reduce administrative work (e.g., use of scribes)
[19]. Also, the American Medical Association instituted “Back to Bedside,” which
is a program designed to encourage bedside teaching and rounds, thus providing
meaningful clinical experiences for attending physician who are charged with
teaching and for the trainees to experience meaningful patient interactions. This
initiative stems from the fact that loss of patient interaction has been associated
with burnout [20]. Leadership to reduce burnout is housed in the “quadruple aim”
that includes physician wellness as one of the goals of healthcare organizations
[21]. A salient example rests in a study of primary care physicians on the west
coast of the United States where leadership decided to put their physician groups
in charge of not only monitoring their own burnout but creating and implementing
their own interventions based on their own needs to ameliorate and prevent burnout
[22]. This intervention was highly effective. The importance of leadership in this
area has been recognized by institutions that have hired directors of clinician well-
ness or thought leaders with other titles who are responsible for monitoring and
improving clinician wellness by collaborating at the leadership level. These initia-
tives speak to the need for change in organizational culture around clinician well-
ness and well-being.
ddressing Burnout in Oncology

A
In oncology specifically, it is important to focus on the unique stressors for oncol-
ogy clinicians in addition to the stressors that are causing burnout and depression in
medicine in general. Given the interpersonal demands of working in oncology, com-
munication skills training is effective for oncology professionals to both enhance
communication with patients and have a positive effect on physician well-being
[23]. However, it is not clear if these results are sustained over time. Some research-
ers have found a parallel between oncology physicians and military personnel where
suicides are also elevated [24]. Programs that highlight creative (i.e., artistic) out-
lets are effective for soldiers and could be highly relevant for oncologists whose
work environment is particularly stress laden with high levels of mortality salience.
In addition, difficult patient conferences (e.g., Schwartz Rounds) and meetings for
oncologists (e.g., “Balint groups”) and even art therapy for staff on oncology units
have been found to be specifically effective [25, 26].
onsidering the Many Causes of Burnout and Related Concepts (e.g.,

C
Resilience)
Studies have also noted many possible directions that may include decreasing the
burden of documentation, clarification, and guidance of administrative tasks, replac-
ing licensing board questions with questions of functionality rather than mental
health diagnosis, encouraging a participatory management style with physicians,
focusing on long-term viability and focus, and instilling a professional responsibil-
ity to care for the self by replenishing meaning, focus, and attention toward clinical
care. The type and level of intervention may depend heavily on the target clinician
group, practice setting, and outcome. Several outcomes have been mentioned in
addition to burnout. These may include compassion fatigue, depression, suicide,
empathy, medical errors, and resilience. These outcomes are defined and described
in Table 12.1. While there is overlap between these outcomes, they are clearly dis-
tinct and may differ based on their root causes and the extent to which they are
derived from workplace factors.
Of note, resilience, and its cultivation and preservation, has been called upon as
an outcome goal that will enhance physician well-being. Interestingly, the related
concept of “hardiness” predates the discussion of burnout and was used historically
to describe the ability to persevere (e.g., function) despite adversity [27]. It is not
tied to workplace necessarily and seems to focus on the individual. The concept
evolved into resilience and essentially asks the question: What is it about those other
clinicians who do not experience burnout that allows them to function or thrive
despite external or internal pressures? [28]. While the cultivation and enhancement
of resilience seems like a laudable goal, a meta-analyses from 2020 found that there
was not a significant effect on physicians who were already in practice [11].
Table 12.1 Definitions of concepts related to burnout

Concept Description
Burnout A syndrome conceptualized as resulting from chronic workplace stress that has
not been successfully managed. Characterized by three dimensions: (1)
feelings of energy depletion or exhaustion; (2) increased mental distance from
one’s job, or feelings of negativism or cynicism related to one’s job; and (3)
reduced professional efficacy
Mindfulness A practice of purposely bringing one’s attention to experiences occurring in the
present moment without judgment. The skill develops through training (e.g.,
meditation) and is derived from sati, a significant element of Buddhist
traditions
Mindfulness- A secular intensive mindfulness training program to assist people with
based stress reduction of stress, anxiety, depression, or pain. It is evidence-based and
reduction typically taught over 8 weeks. It was developed at the University of
(MBSR) Massachusetts Medical Center in the 1970s by professor Jon Kabat-Zinn
Compassion May be referred to as secondary traumatic stress (STS). It is characterized by a
fatigue diminished ability to feel compassion for others along with exhaustion
(emotional and physical). It is described as the negative cost of caring
Resilience The ability to adapt well to circumstances in the face of adversity, trauma,
tragedy, threats, or a significant source of stress. Resilience has been described
as the ability to “bounce back” and can also stimulate personal growth
art 2 A Treatment Plan to Address Clinician Stress

P
and Burnout Inspired by a Buddhist Perspective and Approach
to Individual Well-Being
Although physicians strive to alleviate the suffering of patients and families, the
care of the clinician is frequently neglected, and systems of modern healthcare do
little to address clinician-related maladies brought on by the healthcare work
environment. While the intervention choice to ameliorate and prevent burnout
depends on the clinical setting, many of these desired outcomes overlap (e.g., less
burnout or compassion fatigue, greater resilience, empathy, and enhanced well-
being). Therefore, one intervention type will inevitably address multiple outcomes
to some extent. To date, the data demonstrate that many of the interventions used
to prevent or treat burnout broaden the clinician’s perspective and help reduce the
sympathetic tone of the fight or flight response inherent to stress. In fact, these
effects may represent the mechanisms by which these outcomes are obtained
(e.g., burnout prevention/reduction, depression treatment). In the current evi-
dence-based literature, mindfulness-based stress reduction and CBT techniques,
in addition to organizational interventions, appear to have the greatest and lon-
gest-lasting effects.
The mindfulness teachings, which broaden one’s perspective and reduce anxi-
ety, are based on centuries-old Buddhist philosophy and approaches to living a
fulfilled life. A dedicated program in mindfulness-based stress reduction is highly
recommended for all clinicians. However, the time commitment of formal MBSR
training may be prohibitive. Therefore, essential elements of requisite self-care are
provided in Part 2 with the hope that these concepts will be helpful for all clini-
cians. A case vignette guides the reader through the individual wellness plan,
which involves the following: (1) creating self-awareness; (2) cultivating mindful-
ness; (3) enhancing fitness and sleep quality; (4) tending to relationships; (5) find-
ing meaning and purpose in the practice of medicine; and (6) optimizing workflow
patterns and organizational partnerships and policies that influence physician well-
being (Table 12.2).
Table 12.2 Buddhist-inspired interventions used in the case vignette to address burnout
Intervention Core features
Self-awareness Identifying stress triggers and cognitive distortions
Mindfulness/breathing Being present
Mindful pauses and brief breathing exercises
Body scan
Meditation and yoga
Visualization and guided imagery exercises
Self-compassion
Fitness and high-quality sleep Work-life balance
Self-awareness of the negative effects of perfectionism at work
Learning to say “no”
(continued)
Table 12.2 (continued)

Intervention Core features
Relationships Work-life balance
Establishing healthy boundaries
Quality time with loved ones
Finding meaning and purpose Appreciating daily small accomplishments
in life Focusing on the big picture
Organizational approaches Engagement activities
Training programs in self-awareness, mindfulness, and
narrative medicine
Work environment improvements
Box 1 Case Vignette

Dr. Smith is a mid-career oncologist, and his Monday schedule was terribly
busy. He had 20 patients scheduled for his clinic, and he was also involved in
the care of three of his patients that were admitted. Several encounters were
challenging throughout the day: A patient “Googled” several chemotherapy
treatments and asked Dr. Smith to change his chemo regimen according to the
suggestions that the patient found on the Internet. Dr. Smith was very frus-
trated during that encounter. Another patient was a 45-year-old male with
metastatic pancreatic cancer, not responding to palliative chemo and with
worsening functional status. Dr. Smith had to break the bad news and discuss
a hospice referral with the patient and his wife. The meeting was very emo-
tional because the patient had two young children and his family was devas-
tated to hear the news. Dr. Smith was emotionally exhausted after that meeting.
His day was also interrupted due to several calls from the hospitalists caring
for his patients who were admitted and were not doing well. He ate a sandwich
quickly for lunch because there was no time to eat a proper meal. In the afternoon
Dr. Smith got an email from the chairman of his Department of Medicine inform-
ing him that his oncology division was not meeting the quality and productivity
markers for the quarter and that the institution would be expecting better results
for the next cycle. Dr. Smith has had exceptionally low job satisfaction for the past
few months, and the quality improvement (QI) pressure has been very upsetting
for him. He also received a thank you email from a patient that recently survived
breast cancer in which she expressed her gratitude for his services, but he browsed
very quickly through the message because he had so many emails to check.
He left the clinic late and missed his son’s recital at school, and his wife
and son were upset. After he arrived home, he stayed up late completing med-
ical notes and working on a grant proposal which had a deadline later in the
week. Dr. Smith had joined a gym earlier in the month but was not going
because of his busy schedule. He also has not been in touch with any of his
close friends and other family members, and despite having a few friends at
work, he has had no recent social interactions with them. Dr. Smith has been
experiencing frequent symptoms of burnout for the past several months,
including frustration, emotional exhaustion, and a lack of work satisfaction.
Self-Awareness
Awareness of stress-related symptoms and tracking their activation are fundamen-

tal. Once the clinician identifies his/her common triggers for stress, they can take
steps to de-escalate the stress. Triggers are often unique and vary from person to
person and may be related to past events in each person’s history combined with
their own individual personality traits. Many cognitive behavioral techniques help
clinicians with stress reduction [29, 30].
In one of Dr. Smith’s encounters, he had to deal with a patient who searched for
chemotherapy treatment options on the Internet and then tried to dictate his own
treatment. This was a particular trigger for Dr. Smith. He felt insulted and angry
when a patient with no medical degree or even familiarity with oncology argued that
the Internet-based treatment was more appropriate despite Dr. Smith’s extensive
training and experience. This trigger was coupled with another trigger later in the
day when the Chairman of Medicine’s email called out Dr. Smith’s practice for not
meeting the quality and productivity markers for the cycle. Dr. Smith felt frustrated
because he believed that the administration had set unreasonable goals and they
were disconnected from the daily challenges that frontline clinicians face. The last
trigger, perhaps the last straw, happened when Dr. Smith had to break bad news to a
young patient with pancreatic cancer. Dr. Smith had recently lost many young
patients due to aggressive cancers, and this was starting to undermine his sense of
self-efficacy.
In this case, the patient who wanted to dictate his own treatment set off a stress
cycle that was later escalated by additional triggers that were particularly troubling
for Dr. Smith based on the perception of ridicule (i.e., the Chairman’s email) and
recent experiences (i.e., deaths of young patients). Essentially, this was a bad day
for Dr. Smith with several triggers at once. The effects of a day like this will depend
heavily on his self-awareness into his emotions and why he is feeling a particular
way. Once these triggers are identified, clinicians can deploy strategies to reduce the
stress caused by them. Before Dr. Smith embarked on his day, it would be important
for him to have asked himself the following: What are my triggers? What emotions
and patterns do they bring? (e.g., I get angry and become withdrawn and lash out
at other people).
The practice of modern medicine brings many unique challenges and problems,
but sometimes the emotions around these problems create more suffering than the
problems themselves. The ancient Buddhist parable of the two arrows discusses a
common human behavior related to suffering:
It is said the Buddha once asked a student: ‘If a person is struck by an arrow, is it painful?
If the person is struck by a second arrow, is it even more painful?’
He then went on to explain: ‘In life, we can’t always control the first arrow. However,
the second arrow is our reaction to the first. This second arrow is optional.’
This is sometimes interpreted as “pain is inevitable, but suffering is optional”

[31]. The first arrow causes the physical pain of the injury, and the pain of the
second arrow can be described as how our subsequent thinking about the event
causes further suffering. “Why was I in this war? Why did I get sent to battlefield?
Why was I the only one to get shot? I am angry and I will take revenge”, and so on.
Sometimes the feeling of anger, blaming, and planning revenge can cause much
more suffering than the arrow wound itself. Life will shoot many arrows at health-
care providers, difficult patients, end-of-life situations, unreasonable administra-
tion, and the COVID pandemic, and these are certainly difficult situations.
Unfortunately, it is not possible to control or avoid many of these situations.
However, clinicians, like everyone, have control over how they react to these situa-
tions, and this new approach of conscientiously choosing how one will react to a
trigger may greatly reduce suffering. In other words, the clinician has the option of
saying “Ouch- this hurts, but I will try to take care of this wound” as opposed to
“Ouch-this really huts, why me!?, I will get my revenge!” A self-aware reflection
would be to ask oneself if the anger and blame are helpful or not. While anger is
important to acknowledge and can even promote change, it is often destructive, not
helpful, and can worsen or complicate a situation.
In addition to identifying triggers of stress, awareness of cognitive distortions
can also help clinicians dealing with burnout. Cognitive distortions stem from auto-
matic thoughts that lead people to perceive reality inaccurately. Many common cog-
nitive distortions are well described and include the following: catastrophizing,
filtering (only dwelling on the negative), over-generalizing, all-or-nothing thinking,
jumping to conclusions and personalization, or blaming. These distortions can hap-
pen on different levels of awareness and may require therapy to uncover. But many
cognitive distortions will be revealed and ameliorated by becoming more self-aware
because they can cause intense emotions and their presence can be revealed by not
only acknowledging the emotion but thinking about its origin on a personal level
[32]. That is, identifying one’s personal triggers and cognitive distortions is not
going to solve the many challenges that clinicians face, yet once one is aware of his
or her triggers this can be the first step to initiate strategies to de-escalate the situa-
tion by potentially using mindfulness techniques that will be discussed in the next
section.
Mindfulness
The practice of mindfulness emphasizes “moment to moment purposeful attentive-

ness to one’s own mental processes during everyday work with the goal of practic-
ing with clarity and compassion.” Mindful clinicians attend in a nonjudgmental way
to their own physical and mental processes during ordinary, everyday tasks. This
analytical self-reflection enables physicians to listen attentively to patients’ distress,
recognize their own errors, refine their technical skills, make evidence-based deci-
sions, and clarify their values so that they can act with compassion, technical com-
petence, presence, and insight [18]. Studies indicate that mindfulness training for
practicing clinicians can have an effect on burnout, empathy, and well-being for
clinicians [33, 34].
An important feature of mindfulness is that the practice is simply observational.

The clinician observes thoughts and feelings without doing anything to change
them, elaborate on them, stop them, or alter them. It is a practice about “being” that
incorporates a new and deliberate approach to observation, which ricochets back
serenity and a more equanimous “being” or observer. A mindfulness approach
stands in contrast with the usual emphasis on “doing” for which we are acculturated
to revere and is a very natural state of being as a busy clinician [35]. This shift to
observing concentrated in a state of being can drastically change what one actually
does over time and lead to greater clinical effectiveness as well as physical and
emotional well-being.
There are several ways to incorporate mindfulness in one’s daily clinical prac-
tice. At the core of mindfulness interventions is the concept of “being present.” It is
important to note that the goal is not “being peaceful” all the time but rather being
present to what is in front of us, moment by moment. The clinician who is becoming
mindful will be open to experience what is present at any given moment. It may be
a connection or positive engagement with colleagues and patients or a burst of
anger, frustration, or discomfort. The clinician may witness his or her negative reac-
tions and take action to de-escalate the stressful reactions. This clinician may bear
witness to the suffering of patients and families and experience a new capacity for
empathy and compassion. This newfound capacity to be present and aware of the
richness of our moment-to-moment experience can lead to a sense of peace and joy
even while negative events and emotions are observed.
But it is not possible to be always completely present without experiencing the
influence of our minds (e.g., judgmental thoughts, bodily needs). Practicing mind-
fulness is bringing the mind back to this observational state without harsh judgment
or recourse. It is a constant exercise of coming back to the present moment
repeatedly.
There are several mindfulness techniques that may be easily incorporated in a
daily busy practice. The goal in listing these is to explore how they might be incor-
porated into one’s daily practice. They are suggestions that can be practiced occa-
sionally, daily, or multiple times a day. The best results come with consistent practice
as these suggestions do not work as well on demand if the mind has not trained for it.
Placing dedicated attention to one’s breathing and cultivating mindful (aware-
ness) pauses has been a core meditation technique for thousands of years. There are
well-designed, randomized controlled studies that have demonstrated that breathing-
based meditation techniques significantly reduce anxiety and hyperarousal symp-
toms in individuals [36]. These techniques may be performed throughout one’s
clinic or during other activities that induce stress. In between patients, a clinician
may take three slow deep breaths focusing on the present moment, “resetting” the
brain in between clinical encounters: one breath, pause, two breaths, pause, three
breaths, pause. As the mind wanders, one just observes the thoughts in a nonjudg-
mental way during this dedicated time or moment, allowing them to come and go,
refocusing the attention on coming back to the present breath and the present
moment. In addition, a clinician could easily take a few breaths when washing
hands in between patients and several times per day. By focusing on the sensation
of the water on the hands and taking a few breaths, one can reset his or her mind in
order to leave the prior patient encounter behind and enter the next meeting focusing
on the patient in one’s presence. These periods of reset allow the clinician to con-
sciously decide to be present, which also means not worrying about the patients or
tasks that will be coming next. Worrying about past or future patients does not help
either set of patients and detracts from the patient in the room during the cur-
rent moment.
In addition to breathing and mindful pauses, another meditative technique is the
body check. This brings attention to the body to connect to the present moment and
focus. By breathing mindfully one can achieve focus in the present moment, expe-
riencing the sensation of the air coming in and out. In addition, the body check
allows the clinician to acknowledge the present state of the body focusing again on
the present moment while sitting, walking, or standing. Can I feel my hips while
sitting? Can I feel my feet while standing? In this way, the body check can help to
identify symptoms of stress. For example, some typical signs of stress like retroster-
nal burning, dry cough, or worsening gastroesophageal reflux disease (GERD) may
become apparent with stress. The body check forces the clinician to focus on the
present moment. With time, one will become more aware of these symptoms as they
first start, which allows the clinician to accept their presence, calm the mind, and
take a few breaths to reset one’s mind. As these mindfulness and meditation prac-
tices progress, one may be able to ameliorate these symptoms associated with stress.
A useful question for clinicians who will utilize the body scan method of meditation
is to ask the following: “What are the physical signs of stress that manifest them-
selves in my body? Is it headache? Chest pain? Constipation? Neck pain?” Once the
body scan begins to create more awareness of the psychological and physical trig-
gers of stress, there may be an opportunity to identify the source of stress and act
upon it.
These well-studied approaches (e.g., breathing, mindful pauses, and body check)
involve secular forms of meditation, which may also include more organized medi-
tative or mindful activities such as yoga or sitting meditation [37]. In fact, some
clinicians may prefer sitting meditation, while others may prefer the structure of
yoga, the body scan, or visualization, also called guided imagery. This meditative
technique has been associated with significant acute improvements on stress, mind-
fulness, empathy, and resilience [33]. A brief visualization exercise can be incorpo-
rated into mindful pause, which incorporate slow, intention-filled, or mindful
breaths with a visualization of the clinician’s favorite place. It should be well
described during the exercise. What is your favorite place? What does it feel like to
be there? What are the colors, sounds and sensations of your place? Can you try to
briefly go there in your mind? As providers navigate the many stressful moments of
clinical practice and witness stressful events, it may be helpful to visualize a safe
inner haven for a moment during mindful pauses throughout the day. In addition,
self-compassion can be practiced and used as a meditative technique.
In the case vignette, Dr. Smith had a terrible day in which he felt inadequate and
imperfect. Several issues at work were coupled with his personal life and feelings
about himself. He felt bad that he was not able to save his patient with advanced
pancreatic cancer and felt bad that his practice was not meeting the quality goals for
the fiscal quarter. At the end of the day, he also felt bad that he was not a good father
when he missed his son’s recital. A long tradition of perfectionism exists among
clinicians, which may seem like a good thing at first glance but can lead to compli-
cations and burnout. One can turn the same perfectionism toward oneself and feel
shame, anxiety, and anger, and worry that one is less than perfect. Self-compassion
begins with kindness and inward self-reflective curiosity while acknowledging our
own pain and humanity. Self-compassion has three parts. First, we aim to be kind to
ourselves even when we have not been at our best, realizing that every person has
difficult moments, or moments that fall short of our expectations. Second, we can
focus on our connection to others and humanity and remember that we are not the
only ones struggling with a sense of inadequacy. Lastly, we can always return to
mindfulness and cultivate friendship toward ourselves [38].
A quick self-compassion exercise is the repetition of the self-compassion mantra:
May I love myself just as I am. May I be truly happy. May I find peace in this uncertain
world. May I love and be loved. [39]
Regardless of practicing a mantra meditation, the main goals are to practice accep-
tance of life “as it is” rather than “as we would have wished it to be.” Perfectionism
may be a powerful tool as clinicians strive to become better, but perfectionism can
become a significant source of distress as well. In a sense, modern medicine often
brings a promise of assuredness, but as clinicians know all too well, there are always
unexpected surprises that are encountered and perpetuate a cycle of uncertainty and
negative emotion. Healthcare providers can strive to be good clinicians and aspire
for excellence, but practicing self-compassion is an important step toward burnout
prevention.
Generally, it is recommended that the clinician progress gradually in mindful-
ness techniques by beginning with brief daily meditative mindfulness sessions last-
ing a few minutes and progressing slowly in week-long increments by extending the
practice only slightly 1 week at a time. Several research studies indicate that changes
occur in as short as a 2-week period and that there is a dose effect – the more you do
Box 2: Mindfulness Techniques

Breathing/mindful pauses: As the name implies, these strategies involve the
breath and mindfulness-based pauses, which can be used multiple times
throughout a busy clinical day. For example, a clinician may take three slow
deep breaths focusing on the present moment, “resetting” the brain in between
clinical encounters: one breath, pause, two breaths, pause, three breaths,
pause. A practical way to incorporate breathing exercises is to practice pauses
of mindfulness throughout the day. In addition, the multiple times per day that
clinicians wash their hands may be an opportunity to dedicate to mindfulness
(awareness). By focusing on the sensation of the water on the hands and tak-
ing a few breaths, one can reset his or her mind in order to leave the prior
patient encounter behind and enter the next meeting focusing on the patient in
one’s presence. These periods of reset allow the clinician to consciously
decide to be present, which also means not worrying about the patients or
tasks that will be coming next. Worrying about past or future patients does not
help either set of patients and detracts from the patient in the current moment.
Body check: Bringing attention to your body can be a helpful way to con-
nect to the present moment and focus. Body checks can help us identify
symptoms of stress that are common or unique to our physical natures. With
time, the clinician may become more aware of these symptoms, which allows
the clinician to accept their presence, calm the mind, and take a few breaths to
reset one’s mind.
Meditation: This may be conceptualized as a more formal practice that
involves a sitting meditation and stillness. A more formalized process may be
preferred by some clinicians.
Guided imagery/visualization: Calling up a selected image or scenario
with as much detail as possible. It can be incorporated with mindful pauses
and revisited throughout the workday.
Self-compassion: Kindness to oneself even when goals are not met. Focus
on connections to others and humanity in general while fostering a gentle
relationship with oneself.
every day, and the longer you do it, the more benefits you get. But even a short
dose – 3 minutes or even 3 breaths – can be beneficial [35].
Fitness/High-Quality Sleep
Physical activity and high-quality sleep are associated with significant cognitive
benefits [40, 41], yet the goal of achieving appropriate work-life balance that would
provide for both often remains elusive for healthcare clinicians. There are several
potential strategies that may help clinicians find healthy boundaries, but there is not
one easy solution per se. Competition between work and home life is very common,
in fact, inevitable, and clinicians need to balance priorities and demands by setting
boundaries in a way that is healthy, flexible, and realistic [42]. One should be sure
that perfectionism isn’t getting in the way of achieving work-life balance, to the
extent that is possible. While striving in one’s profession, clinicians often neglect
their own self-care – a common theme in this chapter and book. One may look for
possible strategies to say “no” to mounting obligations. A good question to ask
oneself is: “What is my main goal?” For example, a primary goal of enhanced phys-
ical fitness may preclude extra academic activities during a given time since it may
be unrealistic to achieve both goals simultaneously.
When considering an increase in physical activity to enhance wellness, it is

important to choose a modality that suits your own personality and schedule. Some
prefer outdoor activities, while others prefer the gym, or team sports, etc. Also,
starting slowly and improving progressively through small increments may be
helpful to prevent injuries and increase compliance. But the first step may involve
saying “no” to other activities or projects. Defining these priorities helps establish
healthy boundaries. Another possible way to incorporate exercise into one’s daily
routine may involve simple solutions such as walking to work, if feasible, or just
taking the stairs instead of elevators. Every little bit helps and climbing stairs can
be both an opportunity for exercise and an opportunity for mindful pauses through-
out the day.
Relationships
Human beings are social by design. Family and peer support are integral compo-
nents of well-being that cannot be ignored. In fact, loneliness is a growing problem
in many communities, and social isolation has been identified as an independent
predictor of mortality [43]. For busy clinicians, an old African proverb is universally
applicable:
If you want to go fast, go alone. If you want to go far, go together.
The ability for a clinician to connect with other clinicians at a personal level, in
a way different from their typical clinical duties – with family, friends, or col-
leagues – has also been identified as beneficial in studies aimed at identifying com-
ponents of well-being [37, 44].
How does one prioritize relationships with the demands of work life? The pro-
cess of maintaining and cultivating important relationships will involve saying “no”
to additional professional or work commitments and working on establishing
healthy boundaries. Working on setting more modest or realistic goals at work in
order to open time in your schedule for relationships with friends and family can
have significant benefits. Another consideration is to invest in the “quality” of the
time spent with loved ones. Mindfulness will help reduce distractions while engag-
ing with family and friends allowing for more quality time with family and friends
because one was more mentally present to experience/witness it. The Buddha
famously said the following:
Change is the only constant in life and old age, disease and death will come to us all.
Each meeting with a loved one is a precious moment for which one can be uniquely
present and engaged. Recruiting a mindful demeanor can help inspire meaning dur-
ing these encounters and enhance the quality of these important relationships. The
clinical vignette demonstrated how professional stressors sabotaged Dr. Smith’s
ability to be engaged and present with his family. This can become a vicious cycle.
Important relationships need to be prioritized for their own sake and for that of pro-
fessional well-being as well.
Meaning and Purpose
Reconnecting with one’s purpose as a clinician can provide insight, inspiration, and
motivation to do the work needed to deal with stress. Purpose is an overarching
motivation or goal that the clinician values deeply. There is a tendency to wait for
hugely meaningful moments to bring or define one’s purpose, but meaning is pres-
ent in quotidian and even tedious activities. Mindfulness is a useful vehicle to har-
ness one’s thoughts, slow down, and witness the transient beauty of existence [45].
In the case vignette, Dr. Smith received a thank you message from a patient who had
recently survived cancer, yet he barely glanced at the message, prioritizing other
tasks in his mind. His mind lacked the calmness needed to appreciate the message,
and he missed an opportunity to create greater meaning in his work, which may
have compensated for all the other negative experiences he endured.
One widespread program that has touched many clinicians was developed by
Rachel Remen, author of the bestseller Kitchen Table Wisdom, and incorporated in
many medical schools as The Healer’s Art [37, 46].
Viktor Von Frankl, psychoanalyst and Holocaust survivor, hypothesized that
human beings are driven by a quest to find meaning in their lives. Its presence can
be highly motivating, and its absence can drive one to perish. He noted at Auschwitz
that some prisoners who were starving would pass on their food to others in an act
of self-sacrifice. This is an example of the power associated with the creation of
meaning in one’s life no matter how dire the circumstances. In his famous book
Man’s Search for Meaning [47], Frankl saw three possible sources for meaning: in
love (caring for another person), in courage during difficult times, and in work
(doing something significant for oneself, one’s community, and the world). Meaning
and purpose do not need to be grandiose or earth-shattering as there are infinite
sources of meaning. It can be created from experiences (e.g., connection to love,
beauty, or humor), creativity, courage, and responsibilities. In fact, the creation of
meaning and purpose has been used as the centerpiece of meaning-centered therapy
for patients with cancer and their caregivers, which is derived from Victor Frankl’s
original discoveries [48]. The same principles are universally applicable for clini-
cians as well.
Below are some examples of possible sources of meaning and purpose for clini-
cians [45]:
• Your contributions – to others, to science, and to clinical care

• What you are learning about your craft, either as a clinician or researcher
• Your accomplishments, large or small
• The respect you feel from others
• Your ability to use power wisely and constructively
• The community that you feel that you belong to
• The sense that you have autonomy and control over your work
• Your connection to humanity, your patients, their families, and the quest for help-
ing in the midst of pain
As clinicians navigate the challenges of daily practice, it is easy to get upset over
the many small frustrations that frequently happen. But if the clinician keeps their
focus on the larger picture and is connected to the personal “why” of their work, it
becomes easier to overcome daily obstacles and struggles that lead to suffering and
other long-term consequences.
Interfacing with Organizational Resources
This chapter has focused on the individual clinician’s approach to wellness, which
should be complimented by organizational priorities toward wellness and clinician
resilience. As noted above, studies have shown that the most beneficial effects come
from organizational changes in workflow structure, schedules, and prioritization of
clinician goals. It has been demonstrated convincingly that clinicians thrive when at
least 20% of their time can be devoted to the work activity which they find most
rewarding (e.g., researching a specific topic, teaching residents, administrative
work, a certain type of clinical work, or a procedure) [49]. An open question remains
how to achieve this balance with the demands that organizations face to meet their
financial bottom lines. In general, physician turnover will cost organizations upward
of over one million US dollars in lost revenue, on-boarding, and administration time
in finding new employees to fulfill the work of a clinician who has left due to burn-
out [50]. The economic incentive to find solutions for burnout is huge, especially as
these types of systemic or organizational changes may have positive effects on
many clinicians simultaneously. As an individual, it is important to advocate for
changes to enhance well-being for oneself at the organizational level. The case
vignette demonstrated how the added stress may factor into the clinician’s daily
stressors and perpetuate a cycle of reinforcing negative thoughts.
Conclusion
The Buddha proclaimed that life is suffering as his first noble truth. However, his
third and fourth noble truths reveal that suffering can be relieved by practice along
the right path. These Buddhist tenets along with evidence-based practices are effec-
tive at minimizing the negative consequences of clinician burnout. While the phe-
nomenon of burnout is related to the circumstance of modern healthcare, to suffer,
even in one’s work, is universal, and these practices are beneficial irrespective of
the source.
At the same time, identifying the source of burnout is crucial for individuals and
organizations to consider when identifying interventions for burnout. The evidence-
based approaches reviewed in this chapter are drawn from Buddhist principles and
include cultivation of self-awareness, mindfulness, physical fitness, high-quality

sleep, and trying to find meaning and purpose in one’s clinical work and life and
aligning oneself within one’s organization to support a community of wellness. The
journey toward improving well-being and preventing burnout is arduous. There will
always be challenges and setbacks, but the important thing is to stick with a routine
that allows for wellness to flourish and cultivates clinicians’ growth personally and
professionally. Attention to this area of clinical care (i.e., clinician wellbeing) is
growing, and more information about evidence-based practices for clinicians and
organizations is forthcoming. These are exciting times for the enterprise of clinician
well-being, and it will be especially rewarding to see how these individual changes
may lead to larger organizational changes in healthcare.
Acknowledgments The authors would like to thank Julienne W. Kawai and Kristen Hess
McFarland for reviewing and editing the manuscript.
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Index
A mindfulness, 104, 158, 167–169

Alcohol Use Disorders Identification Test moral distress, 93, 94
(AUDIT), 44 nurturing self-efficacy, 150
Anesthesiologists, 63, 64 oncology, 31, 70, 92, 93, 161
organizational duty, physician, 102
organizational resources, 173
B palliative care, 31
Balint groups, 153 permitting initiative, 149
Bipolar disorder, 3 personal characteristics, 71, 72
Buddhist principles, 173 physician values, 94–96
Buddy systems, 153 physician well-being, 103
Bullying, 138 professional consequences, 91
Burnout, 3, 5, 27, 39, 46, 55–58, 79, 88, 90, professional factors, 70, 71
147, 148 professional values, 94
assessment, 101, 102 purpose, 172, 173
Buddhist principles, 163–164 rebuilding local culture, 105
community, 149 recognition, 149
concepts, 162 relationships, 171
control, 149 resilience, 96–98, 151, 162
Copenhagen Burnout Inventory, 76 reward, 149
COVID-19 pandemic, 33 risk factors, 89, 90
depression, 29 selection strategies, 150
emergency medicine, 32, 33 self-awareness, 165, 166
equity, 149 single item, 77
ethical work climate, 103 stress, 27
experience, 29 structured mentoring programs, 151
fitness/high quality sleep, 170, 171 syndrome, 88, 89
fostering community, 104 tragedy of the commons, 158–160
fostering social support, 150 values, 150
general internal medicine, 31, 32 virtue of resilience, 100
history, 27, 28 well-being index, 78
leadership, 161 wellness programs, 152–154
limiting, 33, 34 worklife dimensions
MBI-HSS, 72–75 associated, 91, 92
measuring, 29, 30 workloads, 148

https://doi.org/10.1007/978-3-030-84785-2
178 Index
C format, 72
Cognitive behavioral therapy (CBT), 5, 160 limitations, 73
Cognitive impairment, 45 shortened two item, 74, 75
Compassion fatigue, 56 Medical Assisting in Dying (MAiD),
Confidentiality, 47 114, 117–121
Copenhagen Burnout Mental health, 6
Inventory (CBI), 76 Mentoring, 151
Mindfulness, 158, 160, 166, 174
Mindfulness-based stress reduction
D (MBSR), 160
Depersonalization (DEP/DP), 27, 28, 72 Moral distress, 6, 127, 128
Depression, 2, 3, 6, 59 global pandemic, 131
burnout, 39 impact, 129–131
diagnosis, 40 interventions, 132, 133
disorder, 39, 40 sources, 128, 129
multifactorial, 38 Moral resilience, 99
prevalence, 40
professional life, 41, 42
treatment, 42 O
Dignity, 11, 13 Oldenburg burnout inventory (OBI), 75
doctor-patient dyad, 14 Oncology, 4
health care system, 15, 16 Organizational injustice, 138, 141
Distress, physicians, 127
P
E Palliative sedation, 115
Embitterment, 6, 141 Personal accomplishment (PA), 28
Emotional exhaustion (EE), 27, 28, 72 Physical fitness, 174
Euthanasia, 6, 113, 114 Physician assisting in dying (PAD), 114,
MAiD, 115–117, 121, 122 117, 118
PAD, 117–120 Physician Health Programs (PHPs), 44, 47
Physicians, 1, 37, 38, 40, 42, 43, 46, 47
burnout among oncologists, 62, 63
H compassion fatigue, 55–57
Harassment, 154 depression, 58, 59
High quality sleep, 174 suicide risk, 60, 61
Physician Worklife Study (PWLS), 77
I
Injustice, 140 R
International Classification of Diseases Relationships, 171
(ICD 10), 39 Resilience, 96–98, 147
M S
Major depressive disorder (MDD), 39 Schwartz center rounds, 153
Maslach Burnout Inventory - Human Service Self-awareness, 174
Survey for Medical Personnel Self-compassion, 169
(MBI-HSS), 72 Social conflicts, 137
benefits, 74 Stigma, 39, 41
data analysis, 73 Substance abuse, 2
Index 179
Substance use disorders W

diagnosis, 45, 46 Well-being index (WBI), 78, 79
epidemiology, 44 Workplace
physicians, 43 embitterment, 141–143
risk factors, 46 injustice, 139
treatment, 47, 48 prevention, embitterment, 143
Suicide, 2, 3, 59–61 responses, 139, 140
social conflicts, 138
V
Visualization, 168

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Depression, Burnout

Insights from Oncology and

ISBN 978-3-030-84784-5 ISBN 978-3-030-84785-2 (eBook)

© Springer Nature Switzerland AG 2022

New York, NY, USA Daniel McFarland

1 The Problem of Burnout, Depression, and Suicide in

10 Embitterment in the Workplace �������������������������������������������������������������� 137

Luca Germano Psychiatry Residency Training Program, Faculty of Medicine and

Michelle B. Riba Department of Psychiatry, University of Michigan, Rogel Cancer

Luigi Grassi, Daniel McFarland, and Michelle B. Riba

The need to understand the psychological burden to be a physician is extremely

© Springer Nature Switzerland AG 2022 1

 eneral Issues About Burnout, Depression, and Suicide

Mental Healthcare of Physicians as an Ethical Duty

To be a physician means to be a professional who practices the “art and science” of

© Springer Nature Switzerland AG 2022 11

Doctor-Patient Dyad and Physician’s Personal Dignity

The Change in the Healthcare System

bureaucracies are inherently impersonal, in contrast with the doctor-patient rela-

The Change in Doctor-Patient Relationship

Patient-centered medicine has become a common theme in the literature [44–47],

The Personhood Behind the Medical Profession

72.0% reporting emotional exhaustion, 68.1% depersonalization and detachment in

 ompassion Fatigue and Moral Distress

fatigue, as well as reduced immunity, risk of cardiovascular and musculoskeletal

Burnout is a prevalent and important occupational hazard, experienced by a multi-

History and Definition of Burnout

© Springer Nature Switzerland AG 2022 27

further and independently characterized by Christina Maslach and colleagues,

1. Emotional exhaustion (EE): the exhaustion domain describes a condition of

A burnout profile is characterized by high levels of emotional exhaustion and

The Experience of Burnout and Its Tragic Implications

Burnout and Overlap with Depression and Compassion Fatigue

In addition to elevated risk for occupational burnout, the prevalence of depression

The Importance of Measuring Burnout

There is considerable variability in how researchers studying physicians, medical

of burnout across populations [14]. A meta-analysis on 65 studies from 1991 to

Burnout Considerations Among Distinct Specialties

The prevalence of burnout among oncologists is similar to that of US physicians

Stressors unique to pain/palliative care physicians include regularly facing difficult

General Internal Medicine and Hospitalists

management of their job and is subjectively considered as a major stressor in the

Burnout During the COVID-19 Pandemic

Trends in Limiting Burnout

changes, fostering communication between members of the healthcare team, and

M. B. Murri · M. Gancitano · F. Antenora

© Springer Nature Switzerland AG 2022 37

Symptom Versus Disorder

Depression Versus Burnout

(3) Significant weight loss or gain or change in appetite

Persistent depressive disorder (formerly known as “dysthymia”) involves

Prevalence of Depression Among Physicians

A broad range of workplace factors likely plays a role in contributing to a higher

Depression in physicians may go underdiagnosed, underreported, and inadequately

Impact on Personal and Professional Life

Untreated depression can have significant and sometimes devastating consequences

Substance Use Disorders in Physicians

The epidemiology of substance use disorders (SUDs) in a medical profession relies

• Mood swings (e.g., irritability, anger, euphoria, and depression)

Some of these behaviors are correlated with a tendency to self-prescribe or

New York, NY, USA Daniel McFarland

1 The Problem of Burnout, Depression, and Suicide in

10 Embitterment in the Workplace �� 137

eneral Issues About Burnout, Depression, and Suicide

Mental Healthcare of Physicians as an Ethical Duty

Doctor-Patient Dyad and Physician’s Personal Dignity

The Change in the Healthcare System

The Change in Doctor-Patient Relationship

The Personhood Behind the Medical Profession

ompassion Fatigue and Moral Distress

History and Definition of Burnout

The Experience of Burnout and Its Tragic Implications

Burnout and Overlap with Depression and Compassion Fatigue

The Importance of Measuring Burnout

Burnout Considerations Among Distinct Specialties

General Internal Medicine and Hospitalists

Burnout During the COVID-19 Pandemic

Trends in Limiting Burnout

Symptom Versus Disorder

Depression Versus Burnout

Prevalence of Depression Among Physicians

Impact on Personal and Professional Life

Substance Use Disorders in Physicians

I ntroduction: Burnout and Compassion Fatigue

Depression and Suicide Risk Among Physicians

Burnout Among Oncologists

Burnout and Suicide Risk Among Other Medical Specialists

Conclusions and Recommendations

Background and Rationale for Focusing on Oncology Providers

Associated Factors that May Influence Burnout

ome of the Professional or Occupational-Related Variables

ome Personal Characteristics or Individual Lifestyle Factors

Summary of Established Tools and Survey Instruments

aslach Burnout Inventory-Human Service Survey for Medical

Shortened Two-Item MBI-HSS

Oldenburg Burnout Inventory (OBI)

Copenhagen Burnout Inventory (CBI)

Single-Item Burnout Measures

The Physician Well-Being Index (WBI)

No Diagnostic Criteria for Burnout

Basic Assessment Screening Suggestions Going Forward

The Burnout Syndrome

Risk Factors Associated with Burnout

Personal and Professional Consequences of Burnout

Work-Life Dimensions Associated with Burnout

thical Dilemmas Associated with Burnout in Oncology: